Every finding on record at Franklin-Simpson Nursing and Rehabilitation Center

Based on interview, record review, and review of facility policy, the facility failed to ensure all allegations of abuse were reported within 24 hours of the event that caused the allegation for 1 of 4 facility reported incidents which were investigated for abuse. The allegation of abuse occurred on 04/24/2026 and was not reported to the State Survey Agency until 05/25/2026. The findings include:Review of facility policy, titled Abuse Prohibition Standard of Practice, last reviewed 03/2026, revealed alleged violations would be reported to the Administrator and / or designee immediately. Alleged violations should be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames.Review of Housekeeping Account Manager's emailed witness statement, which was sent to Assistant Director of Nursing (ADON) on 04/24/2026, revealed the incident that resulted in the allegation occurred on Friday 04/24/2026. Review of Progress Notes dated 04/27/2026 at 8:41 AM by Social Services Director documented she met with Resident (R) 11 at her bedside to inquire on how R11 was feeling following a verbal altercation with a med tech on 04/24/2026. R11 stated she was fine and that she just didn't want to see that man again. R11 reported that she had not experienced any other issues with her medications.Review of the facility's Initial Report revealed the Administrator was notified of the allegation on 05/22/2026.Review of facility's Final Report / Five (5) Day Follow-Up revealed the report was submitted on 05/31/2026.In an additional interview on 07/22/2026 at 9:30 AM with the Housekeeping Account Manager she stated that a couple of months ago (unsure of actual date) she was sitting in her office. She heard Certified Nurse Aide / Kentucky Medication Aide (CNA/KMA) 12 raise his voice and use an inappropriate tone to R11. CNA / KMA11 very loudly stated you'll get your meds when you get your meds. She stated she immediately reported the incident to the Assistant Director of Nursing (ADON) who she thought reported it the Interim Administrator. She stated the day it occurred the facility Administrator was out and there was an interim Administrator who was also out of the building at the time. The Director of Nursing (DON) was not in the facility and that was why she reported to the ADON.In an interview on 07/22/2026 at 2:31 PM with R11 she stated an incident occurred about April 25, 2026. She stated her 1:00 PM medications were late. About 4:00 PM she went to ask about her meds. A nurse saw CNA / KMA12 and got his attention. When 1:00 PM medications were questioned he yelled See all these? They are 1 o'clock meds, too. You throwing a tantrum isn't going to get your med any sooner. She stated she reported the incident to someone but doesn't remember who and also filed a grievance. She was very angered by his response to the point it made her blood pressure go up. She stated she did feel the incident was verbal abuse towards her. Additionally, she stated no other staff member had ever treated her badly or abused her in any way.In an interview on 07/22/2026 at 2:42 PM with former Interim Administrator, he stated he was at this facility during March and April. He had no recollection of anyone reporting an allegation of verbal abuse to him. He asked if the resident filed a grievance and this surveyor replied that yes, a grievance was filed. He had no memory of a grievance related to this situation. In an interview on 07/22/2026 at 3:00 PM with ADON she stated she did remember an incident between CNA/KMA12 and R11. She stated it was reported to her by Housekeeping Account Manager that she had been in her office when she heard raised voices in the hallway. Concerned by the tones, she got up to investigate and heard a heated verbal interaction between CNA/KMA12 and R11 related to medication. It was reported to the ADON that CNA/KMA12 said he would get her medication when he was good and ready. She stated she had no memory of R11's response. ADON asked the Housekeeping Account Manager to write her statement and email it to her. When she received the email statement (04/24/2026), she forwarded it to the Administrator because it was at the point of her returning and I thought she would handle it better than him, referring to the Interim Administrator. Based on the information provided, she believed the behavior of CNA/KMA12 was absolutely not acceptable. She stated she was sure that the Administrator had 40 bazillion emails upon her return and just missed the one regarding this incident, so when it came up in discussion later, she re-forwarded the Housekeeping Account Manager's statement on 05/28/2026.In an interview on 07/22/2026 at 5:37 PM with the Administrator she stated suspected or alleged allegations of abuse were to be reported to her immediately. Safety for the residents was always the first concern. She stated if she was not in the facility at the time, staff were to call or text her. The Administrator stated she always told staff that if they hear something or see something then they are required to say something. She stated she had been on leave and came back to work the beginning of May. When she returned, she was unaware of the situation that had occurred between CNA/KMA12 and R11. While she was out, CNA/KMA12 had been terminated for a no call, no show absence from work. It was during her investigation into that matter she became aware of the allegation of verbal abuse. Based on the allegation of verbal abuse that had been brought to her attention, she suspended CNA/KMA12 while the investigation was ongoing. The Administrator stated it was never appropriate to send an email regarding an allegation of abuse. She stated staff would need to call me.

Based on observation, interview, record review and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for four (4) of 20 sampled Residents (R) (R11, R28, R32, R67) who were unable to freely go outside and one Resident (R32) who had a wander guard in place with no attempts to elope from facility. The findings include:Review of the facility's policy titled, Resident Rights Standard of Practice, dated April of 2024, revealed residents had the right to interact with members of the community and participate in activities both inside and outside of the facility. 1.Review of R11's admission Record revealed the facility admitted the resident on 12/11/2023 with diagnoses which included anxiety disorder and coronary artery disease. Review of R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. During an interview on 06/30/25 at 1:52 PM, R11 he stated the staff only let him hang out either in his room or a common room up near the front of the building. He stated he couldn't be in the hallway or by the nurse's station without them running him back into his room. R11 further stated he had never been told that he could go outside if he signed himself out. He further stated that a couple of years ago, residents used to be able to go outside without supervision, but that he hadn't been outside by himself in about 2 years. R11 stated the place was worse than a prison because if he sat with even his toes outside of his room, staff would come by and tell him to get back in his room. 2.Review of R28's admission Record revealed the facility admitted the resident on 03/11/2025 with diagnoses which included anxiety disorder, cerebral infarction, and major depressive disorder. Review of the R28's MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15, indicating the resident was interviewable. During an interview on 07/03/25 at 1:56 PM, R28 stated she was unaware that she was allowed to sign herself out to sit outside. She stated she had never been outside on the porch without supervision. 3.Review of R32's admission Record revealed the facility admitted the resident on 01/21/2025 with diagnoses which included anxiety disorder, cerebral infarction, and diffuse traumatic brain injury. Review of the MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. During an interview on 07/02/25 at 4:34 PM R32 she stated she had a wander guard on because a long time ago she stepped off the porch to smell the flowers and wasn't supposed to step off the porch, so they put it on her. She stated staff told her that she could not go outside without supervision. R32 stated she really enjoyed going outside and not being able to bothered her. She stated that staff hadn't offered to reevaluate her for elopement. R32 further stated that staff rarely let her out because they stated they were to too busy to go outside with her. 4. Review of R67's admission Record revealed the facility admitted the resident on 11/02/2023 with diagnoses which included cerebral infarction, depression, and generalized muscle weakness. Review of the MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15 indicating the resident was interviewable. In an interview on 07/03/25 at 1:00 PM, R67 she stated didn't know residents were allowed to go outside by themselves. She stated every once in a while, the right Certified Nursing Assistant (CAN) would ask her if she wanted to go outside and sit with her. Other than that, staff have told her they are too busy or short staffed to take her outside. In an interview on 07/03/25 at 11:00 AM, the Director of Nursing (DON) stated that residents could sign themselves out to go outside if they have a high enough BIMS score. He stated R32 had a history of pushing doors which sounded the alarm without letting anyone know. The DON stated he wasn't sure when the last date R32 had been reassessed for elopement, but nursing staff or administration did it at least once a year. In an interview on 07/03/25 at 12:43 PM, Certified Nursing Assistant 8 (CNA8) stated if a resident with a high enough BIMS wanted to go outside, staff would take them out if they could. She further stated it didn't happen that often and residents may not know they need to ask if they want to go outside. In an interview on 07/03/25 at 12:55 PM, Licensed Practical Nurse 5 (LPN 5) stated staff kept a list of when residents who ask to go outside in a binder. If someone with a high enough BIMS, the resident could ask staff and put their name on the list so they can go outside. LPN5 stated if a resident with a high BIMS who was immobile wanted to go outside, they would have to hit their call light to let staff know they wanted to go out. She stated that didn't happen often. Review of the Sign In/Out Binder revealed no documented evidence R11, R28, R32, and R67 had been signing out to go outside and sit on the porch. In an interview with the Administrator on 07/03/2025 at 1:46 PM, she stated residents would ask to go out and can go outside when they want. She stated she had not attended resident counsel, but staff communicated with residents through the meetings and the activities coordinator. She stated staff would take residents with low BIMS outside. She stated R32 walked a lot and has a history of approaching doors, so a wander guard was in place for safety. The Administrator further stated most residents with a wander guard have them in place for safety and are assessed to be elopement risks. She stated those elopement assessments were completed quarterly.

Based on interview, record review and review of facility policy, it was determined the facility failed to implement a person-centered Comprehensive Care Plan which met the resident's medical, nursing, and mental psychosocial needs as identified in the comprehensive assessment for one (1) of six (6) residents, (Resident #1). (Refer to F742, F745, and F841) The facility's failure to develop and implement a comprehensive person-centered plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a Scope and Severity (S/S) of a J, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a J, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on [DATE]. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review revealed on [DATE], the resident displayed changes in his/her behaviors to include the resident voiding on the floor and in the sink. The facility failed to monitor Resident #1 for changes in mood, behavior, and mental status, as per the resident's Comprehensive Care Plan. Therefore on, [DATE] at 1:10 PM, Resident #1 was found unresponsive sitting on the floor with the television cord wrapped around his/her neck. Resident #1 was assessed to have no pulse and pronounced expired. A Partial Extended Survey and removal plan validation were conducted on [DATE] and concluded on [DATE]. The State Survey Agency (SSA) determined the facility implemented the removal plan as alleged on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a S/S of a D, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a D, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a S/S of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Change of Condition Standard of Practice, dated ,d+[DATE], revealed the purpose of the policy was to ensure all interested parties were informed of the patient's/resident's change in health status so that a treatment plan would be developed which was in the best interest of the patient/resident. Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, revised ,d+[DATE], revealed it was the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident. Per review, the comprehensive person-centered care plan was to be consistent with resident rights, include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that had been identified in the facility's comprehensive assessment of the resident. Further review revealed person-centered care meant to focus on the resident and support the resident in making their own choices and having control over their daily lives. In addition, review revealed the facility supported the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Review of the medical record for Resident #1 revealed the facility admitted him/her on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #1's medical record revealed he/she had been his/her own responsible party, and the resident had no family. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately impaired cognition as evidenced by the Brief Interview for Mental Status (BIMS) score of twelve (12). Continued review of the MDS Assessment revealed the facility had assessed Resident #1 to have little interest or pleasure in doing things, poor appetite and no behaviors during this review period. Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed the resident had a change in condition in which the resident was unable to answer the questions to complete the assessment. Therefore, the record review revealed staff who cared for the resident assisted with the assessment. Further review of the assessment revealed a BIMS score could not be obtained as the resident during this assessment was rarely or never understood. Further review revealed the resident was assessed to have short-term and long-term memory problems. The resident was assessed to have moderately impaired decisions with poor cues and required supervision. Continued review revealed the resident had disorganized thinking and was assessed to be unclear or illogical in his/her thoughts. Further review revealed the resident's assessed Moods revealed the resident was experiencing trouble with falling or staying asleep, feeling tired, or having little to no energy, and was short-tempered with staff. Further review of the MDS revealed the facility assessed Resident #1 to be experiencing verbal behavioral symptoms directed towards others and to have a rejection of care. Review of Resident #1's Comprehensive Care Plan revealed no documented evidence the facility had care planned the resident's trouble sleeping, being easily annoyed and short-tempered, supervision, and feeling tired or having little energy it had assessed the resident to have on the MDS Assessments. Review revealed the facility had care planned the resident on [DATE] for his/her psychosocial well-being related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the Comprehensive Care Plan revealed the facility had developed a behavior care plan for Resident #1 upon admission with interventions that included: monitoring for increased signs of Depression (poor appetite, increased weeping); allowing the resident time to verbalize feelings; having the Psychologist and Social Worker visit as needed; and encouraging the resident to participate in programs of their choosing. Additional interventions were added on: [DATE], to encourage the resident to stay out of other residents' rooms; on [DATE] to encourage the resident to utilize the bathroom during times of care; on [DATE], to redirect the resident as appropriate; and on [DATE], to educate staff to clean floor when indicated. Further review of the Comprehensive Care Plan revealed the facility had also care planned Resident #1 for [CONDITION(S)] drug use on [DATE], with interventions to: monitor for changes in mood, behavior and mental status; administer medications as ordered and monitor for effectiveness; observe for side effects of the [CONDITION(S)] medication; and consult the Psychologist as needed. Review of the Care Plan for [CONDITION(S)] Drug Use, dated [DATE], indicated interventions to include; Administer medications as ordered. Monitor effectiveness of medications, approach resident in a calm, gentle manner, Monitor for changes in ability to perform/participate in Activities of Daily Living (ADL's), monitor for changes in mood, behavior and mental status and lastly to observe for side effects of antipsychotic medication. Review of the Nurse's Progress Note, dated [DATE] at 8:22 AM, revealed Resident #1 exhibited a behavior of urinating on the floor, as well as hiding the medication he/she had not taken under a pillow. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Progress Notes revealed Resident #1 exhibited behaviors on: [DATE] of urinating on the floor; [DATE] refusing care and threatening staff; [DATE] voiding on the floor; [DATE] voiding in the sink; [DATE] care refusals, threats to others, entering other residents' rooms and wandering throughout the facility. Further review of the Nurse's Progress Notes revealed: on [DATE] Resident #1 refused his/her PM (nighttime) medications; on [DATE] the resident was wandering; on [DATE] the resident refused his/her shower reporting not feeling well; on [DATE] the resident refused his/her telehealth visit with the Psychologist which was unusual for this resident. In addition, review of the Nurse's Progress Notes revealed on [DATE] Resident #1 was experiencing aggressive behavior towards staff, as well as refusing care and medications. Review further revealed, however, no evidence to support Resident #1 had been placed on increased supervision; or the resident's care plan interventions regarding monitoring for changes in his/her mood, behavior and mental status, was followed. Review of the Psychologist's note, dated [DATE], revealed the Psychologist attempted psychotherapy through telehealth with assistance from Social Services, however, the resident refused, stating, go away. The Psychologist went on to report the resident continued to void in inappropriate areas. Further review revealed the resident had decreased socialization, non-compliance with medications and sporadic verbal aggression. Continued review revealed the resident was having increased delusional thinking and possible sensory-perceptual distortions. She further documented she would see the resident in person next week and would again attempt interventions as allowed by the resident. Interview with Certified Nurse Aide (CNA) #2, on [DATE] at 2:34 PM, revealed the CNAs reported residents' behaviors to the Charge Nurse or Administrator, and the CNAs documented the behaviors in the kiosk. Per CNA #2, the weekend prior to the incident, Resident #1 had been somewhat aggressive, and acting out, and his/her blood pressure had been elevated. Interview with the CNA revealed she reported the resident's elevated blood pressure; however, did not document the resident's behaviors. Interview with CNA #6, on [DATE] at 2:12 PM, revealed Resident #1 had been voiding in his/her room and she reported that information to the nurse. Further interview with CNA #6 revealed she did not document the resident's behavior. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 2:42 PM, revealed if changes in a resident's behavior were noted the nursing staff alerted the Unit Manager and Physician and wrote any verbal orders as received. She revealed the nurses were to review the CNA's documentation in the kiosk, and notify the Social Services Director (SSD) as indicated. Interview with the Psychologist, on [DATE] at 3:28 PM, revealed the resident refused her telehealth visit on [DATE], which was unusual for Resident #1 to decline to see her, and so she had planned an in person visit the following week with the resident. Interview revealed she had also noted Resident #1 was having decreased socialization (staying in his/her room more). She described Resident #1 as being Hypomanic (state of increased energy, exhilaration, and irritability) and as having had trouble with boundaries and rambling thoughts. According to the Psychologist, Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the resident's Primary Care/Attending Physician, on [DATE] at 4:27 PM, revealed that based on the Psychologist's progress note dated [DATE], she believed Resident #1 should have been monitored more closely as the resident was having an increase in sleeping time. Interview with the Social Service Director (SSD), on [DATE] at 3:00 PM, and on [DATE] at 3:12 PM, revealed she performed residents' assessments; however, had not had any idea or impression Resident #1 was depressed. Per the SSD, if she was contacted she tried to see the resident involved in the request. Continued interview revealed the SSD stated she should probably document more in the Nurse's Notes and make any necessary updates to residents' care plans as she had not documented her visits with the resident. The SSD stated she was aware the care plan should be followed but was unaware of how to approach the resident. Additional interview with the Director of Nursing (DON), on [DATE] at 9:45 AM, on [DATE] at 1:11 PM, and on [DATE] at 6:05 PM, revealed Resident #1 had experienced an increase in aggressive behaviors the week prior to the incident. Per the DON, staff had been watching Resident #1; however, had not felt the resident needed increased supervision, and she also felt the resident did not require increased supervision. Continued interview revealed Resident #1's aggression was not new. The DON revealed it was her expectation the residents' care plans be personalized for each resident, updated accordingly, continuously reviewed and followed by staff providing care. Interview with the Administrator on [DATE] at 3:48 PM, and on [DATE] at 6:29 PM, revealed residents' care plans were to be individualized to address each resident's needs. Per the Administrator, residents' care plans were a guide for providing care of each resident and staff should follow the care plan interventions. The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]. 1. The resident expired on [DATE]. An AdHoc QA meeting was held [DATE] to review the adverse event with Resident #1 and to develop an immediate action plan for auditing, education, and monitoring. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, VP of Operations, and the Medical Director (via phone). 2. On [DATE], the Social Service Director (SSD), Unit Manager and/or Director of Nursing (DON) completed a PHQ9 screening on each resident, for a total of eighty-four (84) residents. There were six (6) residents that were assessed to have triggered a score of nine (9), mild depression, or above. 3. The residents' physician was notified by the Director of Nursing (DON) on [DATE] and their current medication regimen was reviewed for the six (6) residents assessed to have depression. There were no new orders or additional recommendations received at that time. 4. The Minimum Data Set (MDS) Nurse and/or DON reviewed the residents' medical records to ensure an applicable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on [DATE]. 5. On [DATE], a care plan review was completed for the six (6) residents who flagged for depression on the PHQ9. This was completed by the DON and SSD to ensure the care plan was current to the residents' diagnosis. Further, the DON and SSD ensured the care plans, related to the residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, on [DATE], the SSD, Unit Manager and/or DON completed a PHQ9 screening on each resident (total eighty-four 84). The PHQ9 was completed monthly for each resident by the SSD, Unit Manager and/or DON for the next three (3) months. For residents triggering with a score of nine (9) or above, the attending physician and/or Medical Director was notified for a medication regimen review to ensure appropriate diagnosis, and updates as indicated in the resident's plan of care. The Vice President of Operations and the DON validated the completion of this initial audit on [DATE] and reported the findings at the AdHoc QA meeting on [DATE]. 6. For additional assessment, the Social Service Director (SSD) requested Psych services to complete an on-site assessment of the six (6) residents. This was completed on [DATE]. Additionally, on [DATE], the Administrator and DON contacted the contracted psychologist to discuss the event and inquire if she had any present concerns with the current residents or any specific care recommendations for individual resident(s). There were no concerns or specific care recommendations identified. The contracted psych services provided on-site support at a minimum of twice monthly, on an as-needed basis. 7. On [DATE], the VP of Operations provided education to the Administrator, DON and SDC on the following: a. If a resident was observed exhibiting a new or increased/changes in existing behavior, this would be immediately reported to the supervisor. This was to include statements of depression or signs/symptoms of depression such as decreased appetite, weeping, and excessive sleeping. b. Any concerns regarding the resident's statements to do self-harm to self or others were to be reported immediately to the supervisor. c. Statements such as I do not want to live, I want to leave this place, I wish to die, were to be immediately reported to the supervisor. d. Supervisors were to report these concerns to the DON and/or SSD for additional assessment and to identify the need for potential mental health referrals. e. Care plans were reviewed and updated to ensure exhibited behaviors were on the plan of care. If a new behavior arose and needed to be added to the care plan, the nurse would go to the behavior care plan in the Electronic Medical Record and add the new behavior as the problem and ensure the added interventions were appropriate for the specific behavior. 8. On [DATE], the DON, SDC and/or the Administrator provided this education to facility staff (all disciplines). This education was completed on [DATE]. A post-test was required with a score of one hundred percent (100%) to verify understanding of content. Any new staff member (including agency) and any staff member that may have been on leave, would receive this education during orientation and/or upon return to work. 9. On [DATE], the Social Services Director was provided education by the Vice President (VP) of Operations regarding Social Services' responsibility in following up on identified resident concerns to the Administrator and DON. Also included was a review of the use of the PHQ9, and addressing any behavior concerns, with the need for documentation and follow-up including the weekly behavior meeting. Also included in this education was information regarding the responsibility of Social Services to include providing therapeutic interventions to cope with social and psychological aspects of a resident's illness, impairment and/or disability and that the corresponding written documentation must be maintained in the resident's medical record. Understanding of the education was validated through discussion and verbal exchange. Additionally, on [DATE], the Administrator attended the morning clinical meeting to validate Social Services was an active participant in review of identified behaviors and assisted with IDT notes and updates to the plan of care accordingly and any follow-up that may be required of Social Services. This would continue a minimum of four (4) weeks and until at which time the QA Committee reviews/approved changes to the monitoring plan. 10. On [DATE], the VP of Operations reviewed the incident regarding Resident #1 with the Administrator and DON and how the role of the Medical Director would provide support under the regulatory guidance of F841 with enhanced communication among providers serving residents. Included in the discussion was the provision of education regarding the regulatory intent of F841 in relation to the Medical Director's role and responsibilities, and how the Medical Director would enhance support for the facility moving forward, such as increased physical presence in the facility and enhanced quality assurance engagement for care coordination among all disciplines providing care and services to residents. 11. The Administrator and DON collaborated with the Medical Director and developed a plan to ensure members of the clinical team reviewed daily progress notes and mood/behavior documentation with physician notification for new behaviors or changes in existing behaviors, as well as updates to the plan of care if applicable. The plan included the following: a. The attending physician and/or Medical Director was to be notified of any new resident identified behavior and/or change in existing resident behavior. b. The attending physician and/or Medical Director would be notified for any resident scheduled or as needed PHQ9 assessment that triggered a score of nine (9) or above to initiate a drug regimen review, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The facility would continue to utilize contracted on-site psychiatric consultation services to further address the needs of applicable residents. d. Notes from the weekly facility behavior/Antipsychotic Medication Use QA meeting would be provided to the Medical Director for review and recommendation. e. Any psych consultation notes and/or recommendations for the week would be provided to the Medical Director at this time to address any potential changes. This was to ensure that the Medical Director had the opportunity to review recommendations from consulting psych services and that understanding of the discussion was validated through discussion and verbal exchange. 12. On [DATE], the clinical management team (DON, ADON, MDS Nurse, SSD, and/or Unit Manager) reviewed the prior twenty-four (24) hour progress notes and CNA behavior documentation for each resident to identify changes in mood/behavior. For any identified documentation, the individual resident would be reviewed for the need for applicable updates to the plan of care and verification of implementation. This would be completed twice daily until at which time the facility QAPI committee determines/approves changes to the monitoring plan. The attending physician was notified of any new or increased behaviors. Any required changes to the resident's plan of care were completed by the DON, ADON, MDS Nurse, SSD and/or Unit Manager. Additionally, an AdHoc QA meeting was held on [DATE] to review the status of the immediate action plan items. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, the Medical Director, and VP of Operations (via phone). Included in this meeting was a review/discussion of the immediate plan to address resident behaviors. No additional recommendations were made at this time. 13. On [DATE], the Administrator spoke with the Medical Director again, and reinforced the regulatory intent of F841 to include the Medical Director responsibility in the implementation of resident care policies. Understanding of the discussion was validated through discussion and verbal exchange. 14. On [DATE], the Administrator and DON, in collaboration with the Medical Director, revised the existing Behavior and Psychoactive Protocol and expanded policy that incorporated additional actions created on [DATE] as part of the Removal Plan. The protocol/policy revision was reviewed and accepted through the facility on [DATE] AdHoc QA meeting. Education on this policy revision was provided by the Administrator and/or DON to facility physicians and members of the IDT including the ADON, MDS Nurse, Social Services Director, and Unit Managers. 15. The Administrator, DON and/or MDS Nurse provided this education to all licensed nurses. The education on the revised policy was completed on [DATE]. 16. QA meetings continued related to planning the implementation at a minimum of twice weekly for four (4) weeks, then a minimum of weekly for eight (8) weeks. AdHoc QAPI meetings reviewed the status of the developed plan for education and monitoring. The meetings were held on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and continued a minimum of twice weekly at this time. The results of the monitoring were reviewed by the facility QAPI committee a minimum of twice weekly while the facility remained in immediate jeopardy. The QAPI committee consisted of but was not limited to, the Administrator, DON, SDC, MDS Nurse, Unit Managers, SSD and the Medical Director. The State Survey Agency validated the removal of immediate Jeopardy on [DATE] as follows: 1. Review of the facility investigation and the nursing progress note, dated [DATE], revealed Resident #1 expired in the facility on [DATE]. Review of the AdHoc QA meeting sign-in sheet, dated [DATE], revealed the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), Minimum Data Set (MDS) Nurse, Unit Managers, Social Services Director (SSD), and the Vice President (VP) of Operation were present. Continued review revealed the Medical Director joined by telephone. Interview with the Administrator, on [DATE] at 10:29 AM, revealed they had an AdHoc meeting, on [DATE], to discuss the adverse event as a team and to develop an immediate action plan for education, monitoring and auditing. 2. Review of the Patient Health Questionnaire (PHQ-9) assessment, dated [DATE], revealed all eighty-four residents (84) residents were assessed by either the SSD, Unit Manager, or the DON. A continued review of the PHQ-9 revealed the facility identified six (6), Resident's #6, #7, #8, #9, #10, and #11, of the eight-four (84) residents to have a score of over nine (9), to indicate depression. a. Review of Resident #6's medical record, dated [DATE], revealed the resident had a PHQ-9 score of twelve (12), which indicated the resident had moderate depression. Further review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 for Resident #6. b. Review of Resident #7's medical record, dated [DATE], revealed the resident had a PHQ-9 score of ten (10), which indicated the resident was moderately depressed. Further review of the MAR, dated [DATE], revealed there were no changes to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed a PHQ-9 on [DATE] for Resident #7. c. Review of Resident #8's medical record, dated [DATE], revealed the resident had a PHQ-9 score of nine (9), which indicated the resident had mild depression. Further review of the MAR for Resident #8, revealed there had been no changes to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed a PHQ-9 on [DATE] for Resident #8. d. Review of Resident #9's medical record, dated [DATE], revealed the resident had a PHQ-9 score of fifteen (15), which indicated moderate severe depression. Review of the MAR for Resident #9, revealed the resident's physician did not make any changes to his/her medications after being notified of the resident's PHQ-9 score. Interview with LPN #4, on [DATE] at 2:39 PM, revealed he had assisted with the PHQ-9 screening on [DATE] for Resident #9. e. Review of Resident #10's medical record, dated [DATE], revealed the resident had a PHQ-9 score of nine (9), which indicated mild depression. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications and resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 screening on [DATE] for Resident #10. f. Review of Resident #11's medical record, on [DATE], revealed the resident had a PHQ-9 score of thirteen (13), indicating the resident was moderately depressed. Review of the MAR, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 screening on [DATE] for Resident #10. 3. Interview with the Director of Nursing (DON), on [DATE] at 10:29 AM, revealed she notified the physician for Resident's #6, #7, #8, #9, #10 and #11 to review the residents' current medication regimen for the residents assessed to have depression. She revealed there were no additional or new orders provided by the physician. 4. Interview with the Director of Nursing, on [DATE] at 10:29 AM, revealed she reviewed the six (6) residents records that flagged for depression to ensure an applicable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed she completed this on [DATE]. 5. Interview with the Director of Nursing (DON), on [DATE] at 10:29 AM, revealed she reviewed the care plans for the six (6) residents who flagged for depression on the PHQ-9. She stated she ensured the care plans were current to the residents' diagnosis. The DON stated she completed this on [DATE]. Further interview, on [DATE] at 10:29 AM, revealed she assigned future PHQ-9 assessments to the SSD and the Unit Manager. Interview with the Social Service Director (SSD), on [DATE] at 10:56 AM; and the Unit Manager (LPN #4), on [DATE] at 2:39 PM revealed they assisted with care plan review and ensured the residents were care planned with their current diagnosis. Interview with the Vice President of Operations, on [DATE] at 2:53 PM, revealed the DON reported the findings of the audits to her. She further stated and then she presented the findings to the AdHoc QA meeting on [DATE]. The VP of Operations revealed the audits reflected the residents care plans and no concerns were noted at that time. 6. Review of Resident's #6, #7, #8, #9, #10, and #11 psych assessments, dated [DATE], revealed the residents' assessments were completed by the Psychologist on [DATE]. Interview with the Psychologist, on [DATE] at 9:07 AM, revealed she came onsite and assessed the six (6) residents that were flagged for depression, on [DATE]. She further stated no concerns were identified. 7. Interview with the VP of Operations, on [DATE] at 2:53 PM, revealed she had educated the Administrator, DON, and the Staff Development Coordinator (SDC) on [DATE] related to residents who exhibited new or increased/changes in existing behavior and that the residents' behaviors should be reported to the supervisor. 8. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the post-test were signed-off by either the Director of Nursing (DON), Staff Development Coordinator (SDC), or the Administrator. Continued review revealed a passing score of one-hundred (100%) percent was required, to ensure understanding of the education. Interviews with Certified Nurse Aide (CNA) #6, on [DATE] at 3:40 PM; CNA #9, on [DATE] at 3:46 PM; Housekeeping/Laundry Supervisor, on [DATE] at 3:56 PM; Business Office Manager (BOM), on [DATE] at 10:13 AM; Dietary Manager, on [DATE] at 10:50 AM; SSD, on [DATE] at 10:56 AM; Activities Director, on [DATE] at 11:20 AM; Minimum Data Set (MDS) Nurse, on [DATE] at 2:52 PM; Staff Development Coordinator (SDC), on [DATE] at 1:10 PM; Licensed Practical Nurse [TRUNCATED]

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure residents received appropriate treatment and services to correct an assessed problem or to attain the highest practicable mental and psychosocial well-being possible for one (1) of six (6) sampled residents, Resident #1. (Refer to F656, F745, and F841) Resident #1 had known diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the facility failed to monitor the resident for changes in his/her behaviors, which delayed appropriate treatment to include increased monitoring and supervision of the resident. Record review revealed on [DATE] at 1:10 PM, staff found Resident #1 sitting on the floor against the wall/table in his/her room with a television cord wrapped around his/her neck. Resident #1 was assessed as non-responsive with no pulse and was pronounced as expired. Record review revealed no documented evidence of Social Services having noted any changes in Resident #1's behaviors, nor of documented evidence of an increase in the supervision of the resident prior to the incident. The facility's failure to ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being were provided has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a Scope and Severity (S/S) of a J, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a J, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on [DATE]. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review revealed on [DATE], the resident displayed changes in his/her behaviors to include the resident voiding on the floor and in the sink. Additionally, a review of the progress notes, dated [DATE], revealed the resident made statements of bodily harm and increased verbal aggression. Further record review revealed on [DATE], the resident began wandering into other residents' rooms. Record Review revealed on [DATE], the resident's Psychologist documented the resident had decreased socialization and sporadic verbal aggression which required increased monitoring/supervision. Record review revealed on [DATE] at 1:10 PM, Resident #1 was found sitting on the floor leaning against the wall/table of his/her room with the cord from the television wrapped around his/her neck. Resident #1 was found unresponsive, had no pulse, and was pronounced expired. A Partial Extended Survey and removal plan validation were conducted on [DATE] and concluded on [DATE]. The State Survey Agency (SSA) determined the facility implemented the removal plan as alleged on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a S/S of a D, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a D, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a S/S of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Change of Condition Standard of Practice, dated ,d+[DATE], revealed the purpose of the policy was to ensure all interested parties were informed of the patient's/resident's change in health status so that a treatment plan would be developed which was in the best interest of the patient/resident. Further review revealed the process would include the facility immediately (as soon as possible/no longer than twenty-four (24) hours) inform the resident, consult the resident's physician, nurse practitioner, or physician assistant, and the resident representative (if applicable and consistent with his/her authority) when there was a significant change in the resident's physical, mental, or psychosocial status. Review of the facility policy titled, Incidents/Accidents Standard of Practice, with a revision date of ,d+[DATE], revealed the purpose of the Incident and Accident Standard of Practice was to ensure the facility environment was as free from accident hazards over which the facility had control. Further review revealed the facility would ensure each resident received adequate supervision and assistive devices necessary to prevent avoidable accidents as according to regulatory guidelines. Interview with the Administrator, on [DATE] at 4:12 PM, revealed the facility had no written policies which addressed residents who had mental health disorder diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician's Orders, dated [DATE], revealed the resident had a Do Not Resuscitate order, (DNR). Additionally, the resident signed the DNR paperwork on [DATE]. Review of Physician's Orders dated for the month of April, revealed the resident was ordered [MEDICATION(S)] 15 milligrams (mg). Further review revealed it was used to treat residents with a Paranoid [CONDITION(S)] diagnosis. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record revealed the facility admitted him/her on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued record review revealed Resident #1 was noted as his/her own responsible party and had no family. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately impaired cognition as evidenced by the Brief Interview for Mental Status (BIMS) score of twelve (12). Continued review of the MDS Assessment revealed the facility had assessed Resident #1 to have little interest or pleasure in doing things, poor appetite and no behaviors during this review period. Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed the resident had a change in condition in which the resident was unable to answer the questions to complete the assessment. Therefore, the record review revealed staff who cared for the resident assisted with the assessment. Further review of the assessment revealed a BIMS score could not be obtained as the resident during this assessment was rarely or never understood. Further review revealed the resident was assessed to have short-term and long-term memory problems. The resident was assessed to have moderately impaired decisions with poor cues and required supervision. Continued review revealed the resident had disorganized thinking and was assessed to be unclear or illogical in his/her thoughts. Further review revealed the resident's assessed Moods revealed the resident was experiencing trouble with falling or staying asleep, feeling tired, or having little to no energy, and was short-tempered with staff. Further review of the MDS revealed the facility assessed Resident #1 to be experiencing verbal behavioral symptoms directed towards others and to have a rejection of care. Record review; however, revealed the facility failed to implement the required supervision, as assessed in [DATE], for moderately impaired decisions with poor cues which required supervision. Additionally, record review revealed the facility failed to develop a treatment plan, as per the facility's policy, when the resident was assessed to have a change in health status, with his/her increased behaviors, to include being short tempered with staff, rejecting care, and having an increase with verbal behavioral symptoms directed towards staff. Review of Resident #1's Comprehensive Care Plan revealed the facility had care planned the resident on [DATE], for his/her psychosocial well-being related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's behavior care plan interventions for Resident #1 implemented upon his/her admission included: allowing the resident time to verbalize feelings; monitoring for increased signs of depression (increased weeping, poor appetite); and Psychologist to visit as needed as well as the Social Worker. Per review, on [DATE] the facility added an intervention to encourage Resident #1 to stay out of other residents' rooms. Review revealed on [DATE], the facility added an intervention to encourage Resident #1 to utilize the bathroom during times of care, and on [DATE], another intervention was added to redirect the resident as appropriate. Further review of Resident #1's Comprehensive Care Plan revealed the facility had care planned for the resident ' s [CONDITION(S)] drug use dated [DATE], with interventions that included: monitoring for changes in mood, behavior, and mental status and consult the Psychologist as needed. Record Review revealed that although the resident was care planned to be monitored for increased signs of depression and to monitor for changes in his/her mood, there was no evidence to support the facility monitored for changes in the resident's behaviors. Review of the Nurse's Progress Notes, dated [DATE] at 8:22 PM by Registered Nurse (RN) #3, revealed the medication nurse reported the resident had been urinating on the floor. Further review revealed staff also reported the resident had been urinating in the sink in his/her room and was seen emptying urine into the sink. Continued review revealed the medication nurse also reported the resident spit out his/her bedtime medications and tried to hide them under the pillow. Continued review revealed the resident's primary care physician was notified. However, there was no evidence to support the resident was monitored for his/her behaviors, to include increased supervision. Review of a Nurse's Progress Notes, dated [DATE] at 12:12 PM, documented by Licensed Practical Nurse (LPN) #2 revealed Resident #1 had elevated blood pressure that morning and the medical doctor was made aware and gave orders to send the resident to the emergency room for evaluation. Further review revealed the resident was notified and stated, NO, I ain't going nowhere. Continued review revealed attempts were made three (3) times to persuade the resident to be seen. Further review revealed that Certified Nursing Assistant (CNA)#1 attempted to recheck the resident's blood pressure and the resident began to threaten bodily harm to staff. Review of the Nurse's Notes dated [DATE] at 7:43 AM, revealed Resident #1 had been voiding on the floor and making threats toward staff. Continued review of the Nurse's Notes for [DATE] revealed at 1:08 PM nursing staff documented Resident #1 had been voiding in the sink again. Review of Nurses Note dated [DATE] at 1:17 AM, revealed Resident #1 had been awake wandering the halls and going in and out of other residents' rooms. Review revealed staff documented the resident was redirected. Review of a Psychologist note, dated [DATE], revealed the Psychologist attempted psychotherapy through telehealth with assistance from Social Services, however, the resident refused, stating, go away. The Psychologist went on to report the resident continued to void in inappropriate areas. Further review revealed the resident had decreased socialization, non-compliance with medications and sporadic verbal aggression. Continued review revealed the resident was having increased delusional thinking and possible sensory-perceptual distortions. She further documented she would see the resident in person next week and would again attempt interventions as allowed by the resident. Review of the facility's five (5) day review, undated, revealed on [DATE] at 1:10 PM, the housekeeper entered Resident #1's room and found the resident slumped over on the floor with the television cord wrapped around his/her neck. Continued review revealed the housekeeper immediately summoned the desk nurse to the room. Review revealed that based on the results of the facility's investigation, the facility was unable to substantiate abuse and/or neglect. Further review revealed the facility had not identified the root cause of the incident. Interview with Certified Nurse Aide (CNA) #2, on [DATE] at 8:41 AM; and on [DATE] at 2:34 PM, revealed she had cared for Resident #1 the weekend before the resident passed away. Per interview with CNA #2, at that time, she would describe Resident #1's behavior as aggressive and acting out. She revealed the resident's blood pressure was elevated and the nurse had been made aware of that information. Interview with CNA #3, on [DATE] at 5:10 PM, revealed she had provided care of Resident #1 in the past and had been assigned to the resident three (3) to four (4) days prior to the incident. CNA #3 stated she noticed the resident often sat in the hallways and/or laid on his/her bed. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 10:21 AM, revealed she had cared for Resident #1 the day prior to the incident, [DATE]. She revealed the resident was more aggressive when talking with staff on that day. Interview with Certified Nurse Aide (CNA) #1, on [DATE] at 10:15 AM, revealed the last time she saw Resident #1 on [DATE] was around 12:30 PM when she picked up the resident's lunch tray. Per CNA #1, Resident #1 had eaten about his/her normal consumption of that lunch meal. Further interview revealed Resident #1 had laid down on his/her bed after lunch and pulled the bed covers over him/her. Interview on [DATE] at 10:42 AM, with the housekeeper, revealed she entered Resident #1's room on [DATE] at 1:10 PM, to clean his/her room, and when she turned around, she saw the resident sitting up on the floor against the nightstand. She stated she noticed Resident #1 had the television cord wrapped around his/her neck, so she immediately ran to get Licensed Practical Nurse (LPN) #2. Per the housekeeper, when she turned around and saw Resident #1 on the floor, she initially thought the resident had fallen until she saw the television cord around his/her neck. Further interview revealed Resident #1 was normally lying on his/her bed asleep at that time of day. In addition, she stated Resident #1's roommate had been sitting outside the door to the room on [DATE] at the time of the incident. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 10:29 AM, revealed she had seen Resident #1 on [DATE], prior to the residents' lunch trays being passed and noted the resident voiding in the sink which was not unusual behavior for the resident. Continued interview revealed Resident #1 had been found unresponsive by the housekeeper and LPN #2 took LPN #3 to the room with her. According to LPN #2, the nurses found Resident #1 sitting on the floor leaning against the nightstand with the television cord wrapped around his/her neck. Continued interview revealed Resident #1's face appeared to be normal in color when the nurses arrived in the room, and she immediately cut the television cord from around the resident's neck. LPN #2 stated she provided a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center chest area of an unresponsive person); however, and there was no gasp for air by Resident #1. She revealed when the nurses assessed Resident #1 the resident had no pulse, respirations or heartbeat and his/her pupils were fixed and not reactive to light. The LPN stated Resident #1's skin was still warm to touch upon assessment. Interview revealed Resident #1 had a DNR status, and therefore, CPR was not initiated. An additional interview, on [DATE] at 2:53 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #1 had a significant other at the time of his/her death. She stated she had not seen changes in Resident #1's behavior and they were not monitoring for behaviors for the resident in his/her medical record. Continued interview revealed Resident #1 had not been on any increased supervision, and the resident was seen by the medical doctor via telehealth visits. LPN #2 revealed Resident #1 had refused his/her medications at times and the doctor had been notified of that information. According to the LPN, Resident #1 had been on [MEDICATION(S)] (an antipsychotic medication) fifteen (15) milligrams (mg) daily and had not been on any other psychiatric medications. Further interview revealed the Administrator called the police on [DATE] after being notified of Resident #1 being deceased . Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at approximately 10:20 AM, revealed on [DATE] the housekeeper had notified her of finding Resident #1 unresponsive in his/her room. LPN #3 stated she immediately went to Resident #1's room at 1:10 PM after the housekeeper notified her. The interview revealed when LPN #3 entered the room she observed the resident sitting on the floor with his/her back against the nightstand beside the bed. She stated she observed Resident #1 with the television cord wrapped around his/her neck. Per the interview, LPN #3 stated Resident #1 had been fully clothed with the zipper of his/her pants undone and the resident had been incontinent of urine. She revealed upon observing Resident #1 she noted the resident's face was pale with no cyanosis of the face. LPN #3 revealed another nurse, LPN #2 had entered the room at the same time as she had, and LPN #2 had cut the television cord away from Resident #1's neck. Continued interview revealed LPN #2 assessed Resident #1's pupils and observed them as fixed (a large pupil completely unresponsive to light). According to LPN #3, Cardiopulmonary Resuscitation (CPR) had not been initiated due to Resident #1 having a do not resuscitate (DNR) status. Further interview revealed Resident #1 had normally been ambulatory and able to toilet himself/herself. Interview with the Unit Manager (UM) on [DATE] at 12:55 PM, revealed on [DATE] Resident #1 refused his/her medications, which he/she refused from time to time. He further revealed the resident's primary physician was made aware. Interview further revealed nursing staff monitored Resident #1 for signs and symptoms related to the use of antipsychotic medication. An additional interview with the Unit Manager, on [DATE] at 3:02 PM, revealed changes in the resident's behavior would affect the residents' level of supervision and might require increased supervision, whether it be every shift, every fifteen (15) minutes or a one-to-one (1:1) supervision level. He revealed that he had been educated on behaviors, and if a resident had behaviors, nursing staff contacted the medical doctor or psychologist to ensure orders were received and carried out. The LPN Unit Manager stated typically the Interdisciplinary Team (IDT) updated residents' care plans; however, most managers could also update the residents' care plans. Interview with Registered Nurse (RN) #3, on [DATE] at 7:12 PM, revealed Resident #1 had been voiding in strange places prior to the incident and had been provided education and redirection. RN #3 stated she documented the voiding incidents in the Nurses Notes, even though that behavior had not been out of character for Resident #1. Interview with the Administrator, Director of Nurse (DON) and Minimum Data Set (MDS) Nurse, on [DATE] at 11:15 AM, revealed they had not seen Resident #1 display any behavior symptoms. Per interview, they made the Physician aware when Resident #1 refused his/her [MEDICATION(S)] medication. Interview revealed Resident #1 was normally oriented but delusional at times. Interview with the Staff Development Coordinator (SDC), on [DATE] at 12:43 PM, revealed Resident #1 went through phases of not taking his/her medications and yelling at staff when he/she did not want to do what staff had asked him/her to do. Per the SDC, taking his/her medications was either hit or miss with Resident #1. Further interview revealed the SDC had not observed any unusual or new behaviors in Resident #1 prior to his/her death. Interview with the Social Services Director (SSD), on [DATE] at 3:00 PM; and on [DATE] at 3:12 PM, revealed she had performed assessments of Resident #1; however, had no idea or impression the resident was depressed. The SSD revealed she should have probably documented more of her visits and observations of the resident in the Nurse's Notes and make the necessary updates in the residents' care plans. She stated she tried to see residents if notified by staff and attempted to talk to the residents on a regular basis. An additional interview with the SSD, on [DATE] at 2:45 PM, revealed she attended as many care plan meetings as possible for residents' behaviors and [CONDITION(S)] medications which were held typically weekly on Fridays. She stated she thought Resident #1's refusal of his/her medications were addressed and the resident's voiding in inappropriate places during the care plan meetings. Per the interview with the SSD, residents' behaviors should always be documented in the Nurse's Notes in residents' medical records. Interview on [DATE] at 9:17 AM with the Pharmacist, employed by the facility's drug vendor, revealed the Pharmacy was made aware Resident #1 missed three (3) doses of his/her [MEDICATION(S)] medication in [DATE]. She stated the side effects of [MEDICATION(S)] could include: anxiety, confusion, fatigue, dizziness and thoughts of suicide which was listed as a warning/caution. Interview with the Director of Nurse (DON), on [DATE] at 9:00 AM; 1:00 PM; and 3:48 PM, revealed the Certified Nursing Assistants (CNA's) were responsible for documenting and informing the nurses of Resident #1's behaviors. The DON further revealed nursing staff were expected to document the residents' behaviors in the Nurse's Notes, and the facility did not keep a flow sheet for staff to document residents' behaviors. The DON revealed the facility did not have a behavioral policy nor a behavior monitoring form for staff to document residents' behaviors on. Further interview revealed staff charted by exception and documented and reported any changes. She further stated Resident #1 had been consistent for the past twelve (12) months. However, review of the resident's Minimum Data Set (MDS) assessment from [DATE] to [DATE] revealed the resident was assessed to have no behaviors in [DATE] to having behaviors noted in [DATE], less than two (2) months apart. An additional interview with the DON, on [DATE] at 9:45 AM, revealed Resident #1 had experienced an increase in aggressive behaviors the week prior to the incident, and the Psychologist and SSD had been notified. Per the DON, the facility utilized a charting by exception system (a system of charting utilized where a notation was made only when there was a deviation from the baseline or expected outcome). Further interview revealed staff had been watching Resident #1; however, had not felt the resident required increased supervision. Interview with the Psychologist, on [DATE] at 3:28 PM, revealed Resident #1 declined to be seen by the Psychologist for the telehealth visit scheduled on [DATE]. The Psychologist stated the telehealth note revealed Resident #1 continued to void in inappropriate places. Further review revealed the resident declined his/her telehealth visit, adding to, go away. Interview revealed that it had been unusual for Resident #1 to decline to see her and she had planned an in-person visit for the following week. According to the Psychologist, she noted Resident #1 had been having decreased socialization, such as staying in his/her room more. She stated Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychologist revealed Resident #1 had reported winning the lottery and having many children. Per the Psychologist, she expected if new behaviors were evident in a resident, then there should be increased supervision of that resident. She described Resident #1 as being Hypomanic (periods of over-active and excited behavior which could have a significant impact on one's day-to-day life) and have had trouble with boundaries and rambling thoughts. Further interview revealed in order for her notes to be communicated to the medical doctor she expected her notes to be passed along for the medical doctor's review by the nursing staff. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 4:47 PM, revealed she worked with the Medical Director and saw residents in the facility at least twice a month. Per the APRN, staff should monitor residents for Depression, changes in their behaviors, hygiene and crying, and report that information to the doctor. The APRN further stated if a resident experienced any of those things, then the supervision of that resident would be increased as needed. Interview with the resident's Primary Care/Attending Physician, on [DATE] at 4:27 PM, revealed she had staff follow the Psychologist's recommendations. Per interview, the physicians communicated through reading each other's progress notes, reviewing residents' medications and talking on the telephone as needed. Further interview revealed the progress note from the Psychologist for [DATE] had not been sent to the medical doctor for review. The State Surveyor read the Psychologist's note to the medical doctor during the interview, and the doctor stated she felt like Resident #1 should have been monitored more closely, as the resident had been having an increase in his/her sleeping time. Interview with the facility's Medical Director, on [DATE] at 2:30 PM, revealed he visited the facility once a month and some of his staff visited more frequently. He stated he had never spoken to Resident #1 personally. Per the interview with the Medical Director, he communicated with the facility's attending Physician/Primary Care Physician to coordinate residents' care. He revealed he did not routinely look over the notes of other Physicians, and did not go over the other doctor's head regarding the care of their assigned residents. According to the Medical Director, if a resident was having a change in condition such as voiding in his/her room, aggressive behaviors, being in their room more than usual, or refusing their medications he expected staff to notify the medical doctor. Further interview revealed if a resident missed his/her medications two (2) days in a row, he expected nursing staff to call him to notify him of that information. Interview with the Administrator, on [DATE] at 3:54 PM and at 4:12 PM, revealed the facility did not have written policies to address residents who had mental health disorders/diagnoses. Further interview revealed this would include when to provide every fifteen (15) minute observations and one-to-one (1:1) supervision for changes in a resident ' s behavior. An additional interview with the Administrator, on [DATE] at 6:29 PM, revealed care plans were to be individualized to address each resident's needs, and staff should follow the care plan interventions. According to the Administrator, care plans were a guide for staff to follow regarding the care of a resident. Continued interview revealed the role of the SSD was to be a liaison between nursing staff and the residents. The Administrator stated staff should get to know the residents, document by exception, and document any behaviors if they were out of the normal for that resident. Per the interview, the role of the facility's Medical Director was to be a part of the Quality Assurance (QA) team and to help out and fill in for other doctors as needed. Further interview revealed the Medical Director should also be knowledgeable and able to assist with the development of the facility's policies and procedures. The Administrator further stated the Medical Director should attend one (1) monthly QA meeting. Lastly, the Administrator revealed it was the expectation that the state and federal regulations would be followed. The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]. 1. The resident expired on [DATE]. An AdHoc QA meeting was held [DATE] to review the adverse event with Resident #1 and to develop an immediate action plan for auditing, education, and monitoring. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, VP of Operations, and the Medical Director (via phone). 2. On [DATE], the Social Service Director (SSD), Unit Manager and/or Director of Nursing (DON) completed a PHQ9 screening on each resident, for a total of eighty-four (84) residents. There were six (6) residents that were assessed to have triggered a score of nine (9), mild depression, or above. 3. The residents' physician was notified by the Director of Nursing (DON) on [DATE] and their current medication regimen was reviewed for the six (6) residents assessed to have depression. There were no new orders or additional recommendations received at that time. 4. The Minimum Data Set (MDS) Nurse and/or DON reviewed the residents' medical records to ensure an applicable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on [DATE]. 5. On [DATE], a care plan review was completed for the six (6) residents who flagged for depression on the PHQ9. This was completed by the DON and SSD to ensure the care plan was current to the residents' diagnosis. Further, the DON and SSD ensured the care plans, related to the residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, on [DATE], the SSD, Unit Manager and/or DON completed a PHQ9 screening on each resident (total eighty-four 84). The PHQ9 was completed monthly for each resident by the SSD, Unit Manager and/or DON for the next three (3) months. For residents triggering with a score of nine (9) or above, the attending physician and/or Medical Director was notified for a medication regimen review to ensure appropriate diagnosis, and updates as indicated in the resident's plan of care. The Vice President of Operations and the DON validated the completion of this initial audit on [DATE] and reported the findings at the AdHoc QA meeting on [DATE]. 6. For additional assessment, the Social Service Director (SSD) requested Psych services to complete an on-site assessment of the six (6) residents. This was completed on [DATE]. Additionally, on [DATE], the Administrator and DON contacted the contracted psychologist to discuss the event and inquire if she had any present concerns with the current residents or any specific care recommendations for individual resident(s). There were no concerns or specific care recommendations identified. The contracted psych services provided on-site support at a minimum of twice monthly, on an as-needed basis. 7. On [DATE], the VP of Operations provided education to the Administrator, DON and SDC on the following: a. If a resident was observed exhibiting a new or increased/changes in existing behavior, this would be immediately reported to the supervisor. This was to include statements of depression or signs/symptoms of depression such as decreased appetite, weeping, and excessive sleeping. b. Any concerns regarding the resident's statements to do self-harm to self or others were to be reported immediately to the supervisor. c. Statements such as I do not want to live, I want to leave this place,

Based on observation, interview, record review and review of facility position descriptions, it was determined the facility failed to provide the medically related social services necessary to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of six (6) residents, Resident #1. Interviews and Record Review revealed the Social Service Director (SSD) was responsible for the residents' mental and psychosocial well-being; however, when Resident #1 experienced a change in condition, related to his/her behaviors, the SSD failed to address the resident's needs. (Refer to F656, F742, and F841) The facility's failure to ensure medically related Social Services were provided has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a Scope and Severity (S/S) of a J, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a J, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on [DATE]. Resident #1 was admitted to the facility with diagnoses that included Generalized Anxiety Disorder and [CONDITION(S)]. Record Review revealed on [DATE], the resident displayed changes in his/her behaviors to include the resident voiding on the floor and in the sink. Additionally, the resident spit out his/her bedtime medications; however, the facility failed to provide increased monitoring and/or supervision when the resident exhibited a change in his/her behavior. Additionally, a review of the progress notes, dated [DATE], revealed the resident made statements of bodily harm and increased verbal aggression. Further record review revealed on [DATE], the resident began wandering into other residents' rooms. The Social Service Director was aware of the resident's increased behaviors; however, failed to maintain ongoing documentation of the social service component to address the resident's behaviors with identified problems, goals, and approaches/interventions. Record review revealed on [DATE] at 1:10 PM, Resident #1 was found sitting on the floor leaning against the wall/table of his/her room with the cord from the television wrapped around his/her neck. Resident #1 was found unresponsive, had no pulse, and was pronounced as expired. A Partial Extended Survey and removal plan validation were conducted on [DATE] and concluded on [DATE]. The State Survey Agency (SSA) determined the facility implemented the removal plan as alleged on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a S/S of a D, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a D, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a S/S of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the Position Description for the Social Services Director (SSD) dated [DATE], revealed it was the SSD's responsibility to plan, develop, organize, implement, evaluate and direct the facility's Social Services Department in accordance with federal, state, and local standards, as well as, established policies and procedures to ensure the medically related emotional needs of residents were met and maintained on an individual basis. Per policy review, the SSD's essential functions included providing therapeutic interventions to assist residents in coping with their impairments or disabilities; the social and psychological aspect of their illnesses as well as their feelings regarding separation from family and community; and physical and emotional loss. The responsibilities of the SSD also included maintaining written documentation in residents' medical records as per facility policy and state and federal guidelines. Continued review revealed the SSD responsibilities included maintaining ongoing written documentation for active cases and developing the social service component of a resident's care plan which identified specific problems, goals, and approaches. Review of the facility's self-report, dated [DATE], revealed the resident was found in his/her room, slumped over with an electrical cord from the television wrapped around his/her neck with no pulse or vitals of any kind. Continued review revealed the coroner and police were notified. Review of the facility's five (5) day summary, undated, revealed the facility conducted an investigation and determined the allegations related to abuse and/or neglect were unsubstantiated, but as a precautionary measure, the facility initiated an audit of all resident care plans who indicated depression on the nine (9) question Patient [Resident] Health Questionnaire (PHQ-9) ( a diagnostic tool used to screen adult patients [residents] in primary care settings for presence and severity of depression) questionnaire. The facility: however, failed to determine the root cause of the resident's death and failed to ensure the resident was monitored for changes in his/her behavior. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included [CONDITION(S)], Generalized Anxiety Disorder, Paranoid [CONDITION(S)], and Impulse Disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately impaired cognition as evidenced by the Brief Interview for Mental Status (BIMS) score of twelve (12). Continued review of the MDS Assessment revealed the facility had assessed Resident #1 to have little interest or pleasure in doing things and a poor appetite. Further review of the assessment revealed the resident was assessed to have no behaviors during this review period. Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed the resident had a change in condition in which the resident was unable to answer the questions to complete the assessment. A BIMS score could not be obtained as the resident during this assessment was rarely or never understood. Further review revealed the resident was assessed to have short-term and long-term memory problems. The resident was assessed to have moderately impaired decisions with poor cues and required supervision. Continued review revealed the resident had disorganized thinking and was assessed to be unclear or illogical in his/her thoughts. A review of the MDS related to the resident's Moods revealed the resident was not interviewed, but rather staff responded on the resident's behaviors. Further review revealed the resident was experiencing trouble with falling or staying asleep, feeling tired, or having little to no energy, and was short-tempered with staff. Further review of the MDS revealed the facility assessed Resident #1 to be experiencing verbal behavioral symptoms directed toward others and to have the rejection of care. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed the facility had care planned the resident for his/her behaviors with interventions that included: encouraging the resident to participate in programs of his/her choice; allowing the resident time to verbalize his/her feelings; have the Psychiatrist and social worker visit as needed; and monitoring for signs of increased depression. Additional interventions were added to the care plan on [DATE] to encourage Resident #1 to stay out of other residents' rooms; on [DATE] to encourage Resident #1 to utilize the bathroom during times of care; and on [DATE], to redirect the resident as appropriate. Review of a Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #2, revealed the resident's blood pressure was elevated and the resident's attending physician was notified. Continued review revealed the resident's attending physician wanted the resident to be sent to the emergency room (ER) for an evaluation and to treat. Further review revealed the resident stated, No. He/she further stated, I ain't going nowhere. Continued review of the documentation revealed that three (3) attempts were made to persuade the resident to go to the ER. Certified Nursing Assistant (CNA) #1 attempted to recheck the resident's blood pressure, and the resident began to threaten bodily harm to staff. Further review of the Progress Note revealed Social Service was made aware; however, there was no documentation to support social service evaluating the resident or maintaining ongoing written documentation for the social service component of a resident's care plan which identified specific problems, goals, and approaches to address the resident's statements of bodily harm, refusal to go to the emergency room , and elevated blood pressure. Review of a Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #2 revealed the resident was seen voiding on the floor and the nurse requested to have the resident to use the toilet. Further review revealed the resident cursed and made bodily harm threats to staff when asked to take a shower. Continued review revealed the LPN reported the incident to social services. Further review revealed LPN # 2 also reported to social services that the resident was observed by staff to void in the sink. However, review of the resident's medical record revealed no social service documentation to include developing the social service component of interventions which identified specific problems, goals, and approaches related to the resident's voiding on the floor and in the sink, threats of bodily harm and refusal to take a shower. Review of the Progress Note, dated [DATE], documented by LPN #2, revealed the resident was found voiding in the sink. Additionally, the resident was found to urinate in a cup and on the floor. The resident was reminded to use the toilet that was attached to his/her room and the resident voiced understanding. Review of a Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #6, revealed the resident refused his/her shower four (4) times during the shift, yelling and cursing at staff with attempts. The resident continued to wander in the hallway, attempting to enter other residents ' rooms. Further review revealed the resident was redirected to not enter other residents' rooms without permission. Review of a Progress Note, dated [DATE], documented by Registered Nurse (RN) #3 revealed that at approximately 12:30 AM, a Certified Nursing Assistant (CNA) informed her the resident was wandering in the hallway, attempting to enter another residents' rooms and was standing in the doorway of the resident when the CNA was coming out of another resident's room. The resident was directed to not enter other residents' rooms without permission. The resident was redirected back to his/her room and Social Service (SS) was notified. Continued review; however, revealed no documentation of the SSD/SS's written documentation in the resident's medical record as per the facility's policy and state and federal guidelines. Review of a Progress Note, documented by Licensed Practical Nurse (LPN) #2, dated [DATE], revealed the resident was seen for disruptive behaviors. Further review revealed the resident's care was provided from a remote location separate from where the resident currently resides by utilizing telemedicine (secure audio-video). Further review revealed psychotherapy via telehealth with assistance from social services; however, the resident refused and stated, go away. The documentation noted staff reported the resident continued to void in inappropriate areas and continued to have decreased socialization, and noncompliance with medications, and sporadic verbal aggression. The Psychologist documented the resident was likely to have increased delusional thinking and possible sensory-perceptual disorientation. She further added she would be in person next week and would again attempt interventions as allowed by the resident. Though the telehealth was assisted by Social Service, there was no documentation provided by Social Service to address the resident's disruptive behaviors, decreased socialization, and his/her refusal of therapy services to provide goals and interventions, to include increased monitoring and/or supervision. Review of the Nurses Note, dated [DATE] at 4:57 PM, revealed at 1:10 PM Resident #1 was found sitting on the floor in his/her room by the housekeeper with the television cord wrapped around the neck. The housekeeper notified the nursing staff. At 1:12 PM, upon entering the room, the nurse found the resident in a seated position under the television with the cord wrapped around the neck. The cord was cut by the nurse, and she checked for a carotid pulse, no pulse was present. At 1:14 PM, the Director of Nursing (DON) and Administrator were called. At 1:15 PM the coroner and police were notified. The coroner arrived at 1:30 PM and pronounced the time of death as 1:30 PM. The police arrived at the facility at 1:40 PM and at 1:43 PM the medical doctor was notified, and orders were received to release the body to the coroner. At 1:52 PM, the coroner left the facility with the remains. Observation of Resident #1's former room, on [DATE] at 9:04 AM, revealed a television bracket was mounted on the wall to the right of the bed; however, no television was in place. Continued observation revealed the wall electrical plug outlets were observed on the wall beneath the television bracket. Interview on [DATE] at 2:12 PM, with Certified Nurse Aide (CNA) #6; at 2:21 PM, with CNA #1; at 2:34 PM, and CNA #2 revealed the CNAs documented their monitoring of residents in the kiosk (a place where they document the residents' care) and reported any changes in behavior in their residents to the nurse/charge nurse or Administrator. CNA #6 stated she had not noted changes in behavior for Resident #1 and had reported the resident voiding in his/her room to the nurse but did not recall what day that was. CNA #1 revealed the SSD spent time talking to Resident #1 but was unsure how often the SSD spoke with the resident. Continued interviews revealed CNA #2 stated when she worked the weekend before the incident involving Resident #1, the resident had been somewhat aggressive and acting out. Further interview with CNA #2 revealed Resident #1's blood pressure had also been elevated that weekend and revealed the SSD/SS was notified. Interview on [DATE] at 2:42 PM, with Licensed Practical Nurse (LPN) #2; and at 3:02 PM, with LPN #7 revealed they had been educated on behaviors and the required documentation. Interview with LPN #2 revealed that if there were changes in a resident's behavior, staff would notify the Unit Manager, and the resident's physician, and would write any verbal orders as received. Continued interview with LPN #2 revealed nurses was to review the CNA's documentation in the kiosk and if indicated, would make written referrals to the SSD. LPN #7 stated staff were to notify the medical doctor, the Psychologist, and the SSD regarding changes in a resident's behaviors. According to LPN #7, if a resident required an increase in supervision staff would perform every fifteen (15) checks on him/her or would place the resident on one-on-one (1:1) supervision if needed. Interview on [DATE] at 3:02 PM, with the Licensed Practical Nurse (LPN) Unit Manager revealed he had been educated on behaviors, and to contact the medical doctor or Psychologist to ensure orders were carried out. Per the LPN Unit Manager, if a resident experienced a change in their behavior, it could require increased supervision, whether it be providing supervision every shift, every fifteen (15) minutes or on a 1:1 level. In addition, the LPN Unit Manager stated the SSD went in and interacted with residents in their rooms quite frequently. Interview on [DATE] at 3:00 PM; on [DATE] at 3:12 PM; on [DATE] at 2:45 PM; and on [DATE] at 11:37 AM and at 3:59 PM, with the Social Services Director (SSD) revealed she performed assessments of residents, which included Resident #1; however, had never had any idea or impression the resident was depressed. She stated she tried to stop and talk with residents on a regular basis and communicate with them; however, it was overwhelming as she did not have an assistant. She revealed if a resident was having changes in their behavior, it should be reported to Nursing Administration. Continued interview revealed if she was contacted by nursing staff or others, she attempted to see the resident involved in the request. The SSD stated she was aware of the resident's behaviors, as they were reported to her; however, she was unsure of how to approach Resident #1. The SSD stated she attended as many IDT and Care Plan meetings as possible regarding behaviors and [CONDITION(S)] medications, which were held weekly, typically on Fridays. She revealed she thought the IDT discussed when Resident #1 refused medications or voided in inappropriate places in those meetings. Further interview revealed Resident #1's behaviors or any resident's behaviors should be documented in the Nurse's Notes of the resident's medical record. Further interview with the SSD revealed she had taken her position at the facility in [DATE] and had completed some online training regarding Dementia and Behaviors since that time. She further stated she assumed she would document her information in the residents' Progress Notes and would probably document more information now in residents' Nurse's Notes. The SSD stated she assisted with the medical staff's telehealth visits. Interview with the Psychologist, on [DATE] at 8:51 AM; and on [DATE] at 10:22 AM, revealed Resident #1 had refused her telehealth visit with him/her on [DATE], which was unusual for the resident as the resident had never declined a visit. According to the Psychologist, Resident #1 had expressed having many children and have won the lottery in the past, which were untrue statements; however, had not had new delusional thoughts prior to the incident. Additional interview on [DATE] at 3:28 PM, with the Psychologist, revealed, in regards to her [DATE] telehealth note for Resident #1, she documented the resident continued to void in inappropriate places, and the resident declined to be seen by the Psychologist that day and told them to go away. Continued interview revealed Resident #1 had been having decreased socialization (staying in his/her room more), and she expected if new behaviors were evident for a resident there would be increased supervision of that resident. The Psychologist stated as it was unusual for Resident #1 to decline to see her, she had planned an in-person visit the following week. She described the resident as being Hypomanic (state of increased energy, exhilaration, and irritability) and having had trouble with rambling thoughts and boundaries. Interview on [DATE] at 9:00 AM; and at 3:48 PM, [DATE] at 9:45 AM; and at [DATE] at 6:05 PM, with the Director of Nursing (DON) revealed Resident #1 had experienced an increase in aggressive behaviors the week prior to the incident, and the Psychologist and SSD/SS were notified of the resident's behaviors. According to the DON, the CNA's told the nurses if a resident was having behaviors, and nursing staff were expected to document that information in the Nurse's Notes. Further interview revealed the facility utilized a charting by exception system of documentation, and staff would document any changes noted and report those changes. The DON further revealed the facility had no behavioral policy, nor any behavior monitoring forms. The DON stated staff had been watching Resident #1; however, had not felt like the resident needed increased supervision. Further interview revealed it was the DON's expectation for the SSD to complete his/her part of the care plan, make referrals, assist with family meetings, deal with residents, and talk and listen to the residents. Interview on [DATE] at 3:48 PM; and on [DATE] at 9:47 AM, with the Administrator revealed the nurses and CNA's saw the facility residents more often than anyone else and were more aware of their behaviors. He stated the nurses documented their information on residents in the Nurse's Notes and the CNA's documented on their residents in the kiosk. The Administrator further revealed facility staff had acted appropriately regarding the incident involving Resident #1. An additional interview on [DATE] at 4:12 PM, and at 6:29 PM, with the Administrator revealed the facility did not have a policy that addressed residents who had a mental health disorder diagnosis. He stated the facility followed State and Federal guidelines to individualize residents' care to meet their needs. The Administrator further revealed the role of the facility's SSD was to act as a liaison between nursing staff and the residents. He stated the SSD and other staff should get to know the residents, document by exception any changes in the residents' medical records, and document any behaviors. The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]. 1. The resident expired on [DATE]. An AdHoc QA meeting was held [DATE] to review the adverse event with Resident #1 and to develop an immediate action plan for auditing, education, and monitoring. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, VP of Operations, and the Medical Director (via phone). 2. On [DATE], the Social Service Director (SSD), Unit Manager and/or Director of Nursing (DON) completed a PHQ9 screening on each resident, for a total of eighty-four (84) residents. There were six (6) residents that were assessed to have triggered a score of nine (9), mild depression, or above. 3. The residents' physician was notified by the Director of Nursing (DON) on [DATE] and their current medication regimen was reviewed for the six (6) residents assessed to have depression. There were no new orders or additional recommendations received at that time. 4. The Minimum Data Set (MDS) Nurse and/or DON reviewed the residents' medical records to ensure an applicable diagnosis relating to the PHQ9 score was in the resident's clinical record. This was completed on [DATE]. 5. On [DATE], a care plan review was completed for the six (6) residents who flagged for depression on the PHQ9. This was completed by the DON and SSD to ensure the care plan was current to the residents' diagnosis. Further, the DON and SSD ensured the care plans, related to the residents assessed with depression, were being implemented through an audit. Additionally, on [DATE], the SSD, Unit Manager and/or DON completed a PHQ9 screening on each resident (total eighty-four 84). The PHQ9 was completed monthly for each resident by the SSD, Unit Manager and/or DON for the next three (3) months. For residents triggering with a score of nine (9) or above, the attending physician and/or Medical Director was notified for a medication regimen review to ensure appropriate diagnosis, and updates as indicated in the resident's plan of care. The Vice President of Operations and the DON validated the completion of this initial audit on [DATE] and reported the findings at the AdHoc QA meeting on [DATE]. 6. For additional assessment, the Social Service Director (SSD) requested Psych services to complete an on-site assessment of the six (6) residents. This was completed on [DATE]. Additionally, on [DATE], the Administrator and DON contacted the contracted psychologist to discuss the event and inquire if she had any present concerns with the current residents or any specific care recommendations for individual resident(s). There were no concerns or specific care recommendations identified. The contracted psych services provided on-site support at a minimum of twice monthly, on an as-needed basis. 7. On [DATE], the VP of Operations provided education to the Administrator, DON and SDC on the following: a. If a resident was observed exhibiting a new or increased/changes in existing behavior, this would be immediately reported to the supervisor. This was to include statements of depression or signs/symptoms of depression such as decreased appetite, weeping, and excessive sleeping. b. Any concerns regarding the resident's statements to do self-harm to self or others were to be reported immediately to the supervisor. c. Statements such as I do not want to live, I want to leave this place, I wish to die, were to be immediately reported to the supervisor. d. Supervisors were to report these concerns to the DON and/or SSD for additional assessment and to identify the need for potential mental health referrals. e. Care plans were reviewed and updated to ensure exhibited behaviors were on the plan of care. If a new behavior arose and needed to be added to the care plan, the nurse would go to the behavior care plan in the Electronic Medical Record and add the new behavior as the problem and ensure the added interventions were appropriate for the specific behavior. 8. On [DATE], the DON, SDC and/or the Administrator provided this education to facility staff (all disciplines). This education was completed on [DATE]. A post-test was required with a score of one hundred percent (100%) to verify understanding of content. Any new staff member (including agency) and any staff member that may have been on leave, would receive this education during orientation and/or upon return to work. 9. On [DATE], the Social Services Director was provided education by the Vice President (VP) of Operations regarding Social Services' responsibility in following up on identified resident concerns to the Administrator and DON. Also included was a review of the use of the PHQ9, and addressing any behavior concerns, with the need for documentation and follow-up including the weekly behavior meeting. Also included in this education was information regarding the responsibility of Social Services to include providing therapeutic interventions to cope with social and psychological aspects of a resident's illness, impairment and/or disability and that the corresponding written documentation must be maintained in the resident's medical record. Understanding of the education was validated through discussion and verbal exchange. Additionally, on [DATE], the Administrator attended the morning clinical meeting to validate Social Services was an active participant in review of identified behaviors and assisted with IDT notes and updates to the plan of care accordingly and any follow-up that may be required of Social Services. This would continue a minimum of four (4) weeks and until at which time the QA Committee reviews/approved changes to the monitoring plan. 10. On [DATE], the VP of Operations reviewed the incident regarding Resident #1 with the Administrator and DON and how the role of the Medical Director would provide support under the regulatory guidance of F841 with enhanced communication among providers serving residents. Included in the discussion was the provision of education regarding the regulatory intent of F841 in relation to the Medical Director's role and responsibilities, and how the Medical Director would enhance support for the facility moving forward, such as increased physical presence in the facility and enhanced quality assurance engagement for care coordination among all disciplines providing care and services to residents. 11. The Administrator and DON collaborated with the Medical Director and developed a plan to ensure members of the clinical team reviewed daily progress notes and mood/behavior documentation with physician notification for new behaviors or changes in existing behaviors, as well as updates to the plan of care if applicable. The plan included the following: a. The attending physician and/or Medical Director was to be notified of any new resident identified behavior and/or change in existing resident behavior. b. The attending physician and/or Medical Director would be notified for any resident scheduled or as needed PHQ9 assessment that triggered a score of nine (9) or above to initiate a drug regimen review, diagnosis review, and review for potential updates to the plan of care. c. The facility would continue to utilize contracted on-site psychiatric consultation services to further address the needs of applicable residents. d. Notes from the weekly facility behavior/Antipsychotic Medication Use QA meeting would be provided to the Medical Director for review and recommendation. e. Any psych consultation notes and/or recommendations for the week would be provided to the Medical Director at this time to address any potential changes. This was to ensure that the Medical Director had the opportunity to review recommendations from consulting psych services and that understanding of the discussion was validated through discussion and verbal exchange. 12. On [DATE], the clinical management team (DON, ADON, MDS Nurse, SSD, and/or Unit Manager) reviewed the prior twenty-four (24) hour progress notes and CNA behavior documentation for each resident to identify changes in mood/behavior. For any identified documentation, the individual resident would be reviewed for the need for applicable updates to the plan of care and verification of implementation. This would be completed twice daily until at which time the facility QAPI committee determines/approves changes to the monitoring plan. The attending physician was notified of any new or increased behaviors. Any required changes to the resident's plan of care were completed by the DON, ADON, MDS Nurse, SSD and/or Unit Manager. Additionally, an AdHoc QA meeting was held on [DATE] to review the status of the immediate action plan items. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, the Medical Director, and VP of Operations (via phone). Included in this meeting was a review/discussion of the immediate plan to address resident behaviors. No additional recommendations were made at this time. 13. On [DATE], the Administrator spoke with the Medical Director again, and reinforced the regulatory intent of F841 to include the Medical Director responsibility in the implementation of resident care policies. Understanding of the discussion was validated through discussion and verbal exchange. 14. On [DATE], the Administrator and DON, in collaboration with the Medical Director, revised the existing Behavior and Psychoactive Protocol and expanded policy that incorporated additional actions created on [DATE] as part of the Removal Plan. The protocol/policy revision was reviewed and accepted through the facility on [DATE] AdHoc QA meeting. Education on this policy revision was provided by the Administrator and/or DON to facility physicians and members of the IDT including the ADON, MDS Nurse, Social Services Director, and Unit Managers. 15. The Administrator, DON and/or MDS Nurse provided this education to all licensed nurses. The education on the revised policy was completed on [DATE]. 16. QA meetings continued related to planning the implementation at a minimum of twice weekly for four (4) weeks, then a minimum of weekly for eight (8) weeks. AdHoc QAPI meetings reviewed the status of the developed plan for education and monitoring. The meetings were held on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and continued a minimum of twice weekly at this time. The results [TRUNCATED]

Based on interview, record review and review of the facility's Medical Director's responsibilities, it was determined the Medical Director failed to implement resident care policies for behaviors and failed to coordinate the medical care within the facility as evidenced by deficient practice in the following areas. (Refer to F656, F742 and F745). The facility's failure to ensure the Medical Director was responsible for implementation of the residents' care policies and the coordination of medical care in the facility has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a Scope and Severity (S/S) of a J, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a J, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on [DATE]. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review revealed on [DATE], the resident displayed changes in his/her behaviors to include the resident voiding on the floor and in the sink. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . She further documented the resident was likely to have increased delusional thinking and possible sensory-perceptual disorientation. However, the facility's Medical Director failed to communicate with the resident's Primary Care/Attending Physician and/or Psychologist to coordinate care, related to increased monitoring/supervision of the resident. Additionally, interviews revealed the facility did not have policies to address residents with mental health disorders. Record review revealed on [DATE] at 1:10 PM, Resident #1 was found sitting on the floor leaning against the wall/table of his/her room with the cord from the television wrapped around his/her neck. Resident #1 was found unresponsive, had no pulse, and was pronounced expired. A Partial Extended Survey and removal plan validation were conducted on [DATE] and concluded on [DATE]. The State Survey Agency (SSA) determined the facility implemented the removal plan as alleged on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan (F656) at a S/S of a D, 42 CFR 483.40 Behavioral Health, (F742 and F745) at a S/S of a D, and 42 CFR 483.70 Administration, Responsibilities of Medical Director (F841) at a S/S of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Interview with the Administrator on [DATE] at 4:12 PM revealed the facility had no written policies which addressed residents who had mental health disorder diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Medical Director Agreement, dated [DATE], revealed the Medical Director would ensure facility residents received quality medical care. Per interview, the Medical Director was also to perform all the duties of a Medical Director as required by applicable law. Continued review revealed the Medical Director's duties included, without limitation, implementing resident care policies and coordinating medical care in the facility. The Medical Director agreed to the following responsibilities and to perform the following functions: Be responsible for the medical direction and overall coordination of medical care in the facility. Review and sign all incident reports, identify hazards to health and safety, and provide recommendations to the facility's Administrator to ensure a safe and sanitary environment for residents, guests, and personnel. Continued review of the Medical Director Agreement, dated [DATE], revealed the Medical Director was responsible for developing a liaison with, and monitor the activities of, attending physicians in an effort to ensure effective and appropriate medical care and provide oversight and supervision of physician services and the medical care of residents. The Medical Director participated in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to admissions, transfers, and discharges; infection control; use of restraints; physician privileges and practices; and responsibilities of non-physician health care workers, (e.g., nursing, rehabilitation therapies, and dietary services in resident care, emergency care, and resident assessment and care planning). Further review revealed the Medical Director was responsible for policies related to accidents and incidents and the overall quality of care of the residents. Continued reviewof the Medical Director Agreement revealed the Medical Director was responsible for ensuring that the care policies were implemented and would be available for consultation at all other times with the facility's Administrator and Director of Nursing in evaluating the adequacy of the facility and its staff to meet the psychosocial as well as the medical and physical needs of specific residents. Further, the Medical Director would be available as a resource on resident care issues and developments. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed the resident had a change in condition in which the resident was unable to answer the questions to complete the assessment. Further review of the MDS revealed a Brief Interview for Mental Status (BIMS) score could not be obtained as the resident during this assessment was rarely or never understood. Further review revealed the resident was assessed to have short-term and long-term memory problems. The resident was assessed to have moderately impaired decisions with poor cues and required supervision. Continued review revealed the resident had disorganized thinking and was assessed to be unclear or illogical in his/her thoughts. Continued review of the resident's Quarterly MDS Assessment, dated [DATE], revealed the MDS related to the resident's Moods revealed the resident was not interviewed, but rather staff responded on the resident's behaviors. Further review revealed the resident was experiencing trouble with falling or staying asleep, feeling tired, or having little to no energy, and was short-tempered with staff. Further review of the MDS revealed the facility assessed Resident #1 to be experiencing verbal behavioral symptoms directed toward others and to have rejection of care. Review of Resident #1's Comprehensive Care Plan revealed the facility care planned him/her [DATE], for psychosocial wellbeing related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 for [CONDITION(S)] drug use on [DATE], with interventions that included monitoring the resident for changes in his/her mood, behavior and mental status; consulting the Psychologist as needed, and observing for side effects of his/her [CONDITION(S)] medication. Further review of the Comprehensive Care Plan revealed upon admission to the facility Resident #1 was care planned for his/her behavior with interventions including: monitoring for increased signs of Depression; having the Psychologist and Social Worker visit the resident as necessary, and allowing the resident to verbalize his/her feelings. Further review of Resident #1's medical record revealed even though he/she had interventions to monitor his/her mood, behavior, mental status, and for increased signs of Depression, there was no documented evidence of such monitoring for the resident noted. Record review and interview revealed Resident #1 had been staying in his/her room more, displaying aggressive behaviors and urinating in places other than his/her bathroom; however, review of the medical records revealed no documented evidence the facility's Medical Director communicated with the resident's Primary/Attending Physician, the resident's Psychologist, and/or developed/reviewed mental health disorder policies with his staff. Therefore, on [DATE] at 1:10 PM staff found Resident #1 sitting on the floor in his/her room unresponsive with a television cord wrapped around his/her neck. Resident #1 was pronounced as expired. Review of the resident's Psychologist's Note, dated [DATE], revealed the resident was seen for disruptive behaviors. Further review revealed the resident refused and stated, go away. The documentation noted staff reported the resident continued to void in inappropriate areas and continued to have decreased socialization, and noncompliance with medications, and sporadic verbal aggression. The Psychologist documented the resident was likely to have increased delusional thinking and possible sensory-perceptual disorientation. She further added she would be in person next week and would again attempt interventions as allowed by the resident. Review of the Primary Care/Attending Physician notes, dated [DATE], revealed the resident made complaints of neck and shoulder pain and a telehealth visit was completed with the resident's primary care physician. The resident; however, refused to be examined at that time. Interview with the Psychologist, on [DATE] at 8:51 AM, and on [DATE] at 3:28 PM, revealed she had been shocked when she learned of the incident involving Resident #1. The Psychologist stated on [DATE], Resident #1 had a telehealth visit scheduled with her; however, the resident had refused the telehealth visit that day and told her to go away. Continued interview revealed it had been unusual for Resident #1 to decline to see her, and therefore, she had planned an in-person visit with the resident the following week. Per the interview, on [DATE], she was aware Resident #1 continued to void in inappropriate places, and had been having decreased socialization (staying in room more). According to the Psychologist, she was aware Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would expect if new behaviors were evident in the resident there would have been increased supervision of him/her. Further interview revealed she expected her progress notes to be passed along to the Medical Director and reviewed by the facility's nursing staff; however, stated there would be a day or two (2) lag in getting her progress notes to the facility to be passed along to the Primary Care/Attending Physician. Interview with the resident's Primary Care/Attending Physician, on [DATE] at 3:01 PM, and on [DATE] at 4:27 PM, revealed she had attempted a telehealth visit with Resident #1 the morning of [DATE] (prior to the incident that same day). She stated, however, that Resident #1 told her to leave him/her alone. Continued interview revealed the facility's Physicians communicated with each other by reading one another's progress notes, reviewing residents' medications, and talking on the telephone as needed. She revealed the Psychologist's progress note from [DATE] had not been sent to her; however, if she had received it she would have followed the Psychologist's recommendations. After having the Psychologist's progress note reviewed with her, the Primary Care Physician stated she felt like Resident #1 should have been monitored more closely by the facility, as the resident had been having an increase in his/her sleeping time. Interview with the Director of Nurse (DON), on [DATE] at 9:45 AM, and on [DATE] at 6:05 PM, revealed Resident #1 had experienced an increase in aggressive behaviors the prior week to the incident, which she stated the Psychologist and Social Services Director (SSD) had been notified of. Per the DON, staff had been watching Resident #1; however, had not felt the resident needed increased supervision. Continued interview revealed it was her expectation for the Medical Director to be: a resource and overseer for the facility; provide care for his own residents, and be available if something happened. She stated the facility was to report any concerns identified to the Medical Director. Further interview revealed the Medical Director attended monthly Quality Assurance Meetings; however, thus far she had seen no involvement with the facility's policies from the Medical Director. Interview with the Administrator on [DATE] at 3:48 PM, on [DATE] at 3:54 PM, and on [DATE] at 4:12 PM, and at 6:29 PM, revealed he had not seen any different or unusual changes in Resident #1, and felt there had been nothing to indicate the need for increased supervision of Resident #1. Per the Administrator, the facility had no written policies which addressed residents who had mental health disorder diagnoses, nor for increased supervision, such as every fifteen (15) minute observations, one-to-one (1:1) supervision, nor for behaviors. Continued interview revealed the facility followed state and federal guidelines to individualize residents' needs. According to the Administrator, the role of the facility's Medical Director was to be a part of its Quality Assurance (QA) facility team, and to help out and fill in for other doctors as needed. Further interview revealed the Medical Director was also to be knowledgeable and able to assist with the facility's policies and procedures. The Administrator further revealed the Medical Director was to attend one (1) monthly QA meeting. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 4:47 PM, revealed she worked with the Medical Director to provide care for residents in the facility. The APRN stated she saw residents in the facility at least twice a month. Further interview revealed facility staff should monitor the residents for Depression, changes in behavior, hygiene and crying, and report any changes to the doctor. The APRN further revealed if changes were reported then supervision of the resident would be increased as needed. Interview with the facility's Medical Director, on [DATE] at 7:11 PM, and on [DATE] at 2:30 PM, revealed he visited the facility once a month and some of his staff visited more often than that. He stated that he had never spoken to Resident #1. The Medical Director stated to coordinate the care of the facility's residents, he would communicate with the resident's attending physician. Per the Medical Director, he did not routinely look over the progress notes of the facility's other Physicians, and he would not go over the other doctors' heads regarding the care of their residents. Continued interview revealed if a resident had been having a change in a condition such as voiding in the room, aggressive behavior, being in the room more than usual or refusing medications he expected staff to notify the resident's Primary Care/Attending Physician. Continued interview with the Medical Director revealed after the incident involving Resident #1, the facility held a quality meeting and he had been notified immediately of the incident which was tragic and sad. The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]. 1. The resident expired on [DATE]. An AdHoc QA meeting was held [DATE] to review the adverse event with Resident #1 and to develop an immediate action plan for auditing, education, and monitoring. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, VP of Operations, and the Medical Director (via phone). 2. On [DATE], the Social Service Director (SSD), Unit Manager and/or Director of Nursing (DON) completed a PHQ9 screening on each resident, for a total of eighty-four (84) residents. There were six (6) residents that were assessed to have triggered a score of nine (9), mild depression, or above. 3. The residents' physician was notified by the Director of Nursing (DON) on [DATE] and their current medication regimen was reviewed for the six (6) residents assessed to have depression. There were no new orders or additional recommendations received at that time. 4. The Minimum Data Set (MDS) Nurse and/or DON reviewed the residents' medical records to ensure an applicable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on [DATE]. 5. On [DATE], a care plan review was completed for the six (6) residents who flagged for depression on the PHQ9. This was completed by the DON and SSD to ensure the care plan was current to the residents' diagnosis. Further, the DON and SSD ensured the care plans, related to the residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, on [DATE], the SSD, Unit Manager and/or DON completed a PHQ9 screening on each resident (total eighty-four 84). The PHQ9 was completed monthly for each resident by the SSD, Unit Manager and/or DON for the next three (3) months. For residents triggering with a score of nine (9) or above, the attending physician and/or Medical Director was notified for a medication regimen review to ensure appropriate diagnosis, and updates as indicated in the resident's plan of care. The Vice President of Operations and the DON validated the completion of this initial audit on [DATE] and reported the findings at the AdHoc QA meeting on [DATE]. 6. For additional assessment, the Social Service Director (SSD) requested Psych services to complete an on-site assessment of the six (6) residents. This was completed on [DATE]. Additionally, on [DATE], the Administrator and DON contacted the contracted psychologist to discuss the event and inquire if she had any present concerns with the current residents or any specific care recommendations for individual resident(s). There were no concerns or specific care recommendations identified. The contracted psych services provided on-site support at a minimum of twice monthly, on an as-needed basis. 7. On [DATE], the VP of Operations provided education to the Administrator, DON and SDC on the following: a. If a resident was observed exhibiting a new or increased/changes in existing behavior, this would be immediately reported to the supervisor. This was to include statements of depression or signs/symptoms of depression such as decreased appetite, weeping, and excessive sleeping. b. Any concerns regarding the resident's statements to do self-harm to self or others were to be reported immediately to the supervisor. c. Statements such as I do not want to live, I want to leave this place, I wish to die, were to be immediately reported to the supervisor. d. Supervisors were to report these concerns to the DON and/or SSD for additional assessment and to identify the need for potential mental health referrals. e. Care plans were reviewed and updated to ensure exhibited behaviors were on the plan of care. If a new behavior arose and needed to be added to the care plan, the nurse would go to the behavior care plan in the Electronic Medical Record and add the new behavior as the problem and ensure the added interventions were appropriate for the specific behavior. 8. On [DATE], the DON, SDC and/or the Administrator provided this education to facility staff (all disciplines). This education was completed on [DATE]. A post-test was required with a score of one hundred percent (100%) to verify understanding of content. Any new staff member (including agency) and any staff member that may have been on leave, would receive this education during orientation and/or upon return to work. 9. On [DATE], the Social Services Director was provided education by the Vice President (VP) of Operations regarding Social Services' responsibility in following up on identified resident concerns to the Administrator and DON. Also included was a review of the use of the PHQ9, and addressing any behavior concerns, with the need for documentation and follow-up including the weekly behavior meeting. Also included in this education was information regarding the responsibility of Social Services to include providing therapeutic interventions to cope with social and psychological aspects of a resident's illness, impairment and/or disability and that the corresponding written documentation must be maintained in the resident's medical record. Understanding of the education was validated through discussion and verbal exchange. Additionally, on [DATE], the Administrator attended the morning clinical meeting to validate Social Services was an active participant in review of identified behaviors and assisted with IDT notes and updates to the plan of care accordingly and any follow-up that may be required of Social Services. This would continue a minimum of four (4) weeks and until at which time the QA Committee reviews/approved changes to the monitoring plan. 10. On [DATE], the VP of Operations reviewed the incident regarding Resident #1 with the Administrator and DON and how the role of the Medical Director would provide support under the regulatory guidance of F841 with enhanced communication among providers serving residents. Included in the discussion was the provision of education regarding the regulatory intent of F841 in relation to the Medical Director's role and responsibilities, and how the Medical Director would enhance support for the facility moving forward, such as increased physical presence in the facility and enhanced quality assurance engagement for care coordination among all disciplines providing care and services to residents. 11. The Administrator and DON collaborated with the Medical Director and developed a plan to ensure members of the clinical team reviewed daily progress notes and mood/behavior documentation with physician notification for new behaviors or changes in existing behaviors, as well as updates to the plan of care if applicable. The plan included the following: a. The attending physician and/or Medical Director was to be notified of any new resident identified behavior and/or change in existing resident behavior. b. The attending physician and/or Medical Director would be notified for any resident scheduled or as needed PHQ9 assessment that triggered a score of nine (9) or above to initiate a drug regimen review, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The facility would continue to utilize contracted on-site psychiatric consultation services to further address the needs of applicable residents. d. Notes from the weekly facility behavior/Antipsychotic Medication Use QA meeting would be provided to the Medical Director for review and recommendation. e. Any psych consultation notes and/or recommendations for the week would be provided to the Medical Director at this time to address any potential changes. This was to ensure that the Medical Director had the opportunity to review recommendations from consulting psych services and that understanding of the discussion was validated through discussion and verbal exchange. 12. On [DATE], the clinical management team (DON, ADON, MDS Nurse, SSD, and/or Unit Manager) reviewed the prior twenty-four (24) hour progress notes and CNA behavior documentation for each resident to identify changes in mood/behavior. For any identified documentation, the individual resident would be reviewed for the need for applicable updates to the plan of care and verification of implementation. This would be completed twice daily until at which time the facility QAPI committee determines/approves changes to the monitoring plan. The attending physician was notified of any new or increased behaviors. Any required changes to the resident's plan of care were completed by the DON, ADON, MDS Nurse, SSD and/or Unit Manager. Additionally, an AdHoc QA meeting was held on [DATE] to review the status of the immediate action plan items. This meeting was attended by the Administrator, DON, SDC, MDS Nurse, Unit Managers, Social Services, the Medical Director, and VP of Operations (via phone). Included in this meeting was a review/discussion of the immediate plan to address resident behaviors. No additional recommendations were made at this time. 13. On [DATE], the Administrator spoke with the Medical Director again, and reinforced the regulatory intent of F841 to include the Medical Director responsibility in the implementation of resident care policies. Understanding of the discussion was validated through discussion and verbal exchange. 14. On [DATE], the Administrator and DON, in collaboration with the Medical Director, revised the existing Behavior and Psychoactive Protocol and expanded policy that incorporated additional actions created on [DATE] as part of the Removal Plan. The protocol/policy revision was reviewed and accepted through the facility on [DATE] AdHoc QA meeting. Education on this policy revision was provided by the Administrator and/or DON to facility physicians and members of the IDT including the ADON, MDS Nurse, Social Services Director, and Unit Managers. 15. The Administrator, DON and/or MDS Nurse provided this education to all licensed nurses. The education on the revised policy was completed on [DATE]. 16. QA meetings continued related to planning the implementation at a minimum of twice weekly for four (4) weeks, then a minimum of weekly for eight (8) weeks. AdHoc QAPI meetings reviewed the status of the developed plan for education and monitoring. The meetings were held on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and continued a minimum of twice weekly at this time. The results of the monitoring were reviewed by the facility QAPI committee a minimum of twice weekly while the facility remained in immediate jeopardy. The QAPI committee consisted of but was not limited to, the Administrator, DON, SDC, MDS Nurse, Unit Managers, SSD and the Medical Director. The State Survey Agency validated the removal of immediate Jeopardy on [DATE] as follows: 1. Review of the facility investigation and the nursing progress note, dated [DATE], revealed Resident #1 expired in the facility on [DATE]. Review of the AdHoc QA meeting sign-in sheet, dated [DATE], revealed the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), Minimum Data Set (MDS) Nurse, Unit Managers, Social Services Director (SSD), and the Vice President (VP) of Operation were present. Continued review revealed the Medical Director joined by telephone. Interview with the Administrator, on [DATE] at 10:29 AM, revealed they had an AdHoc meeting, on [DATE], to discuss the adverse event as a team and to develop an immediate action plan for education, monitoring and auditing. 2. Review of the Patient Health Questionnaire (PHQ-9) assessment, dated [DATE], revealed all eighty-four residents (84) residents were assessed by either the SSD, Unit Manager, or the DON. A continued review of the PHQ-9 revealed the facility identified six (6), Resident's #6, #7, #8, #9, #10, and #11, of the eight-four (84) residents to have a score of over nine (9), to indicate depression. a. Review of Resident #6's medical record, dated [DATE], revealed the resident had a PHQ-9 score of twelve (12), which indicated the resident had moderate depression. Further review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 for Resident #6. b. Review of Resident #7's medical record, dated [DATE], revealed the resident had a PHQ-9 score of ten (10), which indicated the resident was moderately depressed. Further review of the MAR, dated [DATE], revealed there were no changes to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed a PHQ-9 on [DATE] for Resident #7. c. Review of Resident #8's medical record, dated [DATE], revealed the resident had a PHQ-9 score of nine (9), which indicated the resident had mild depression. Further review of the MAR for Resident #8, revealed there had been no changes to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed a PHQ-9 on [DATE] for Resident #8. d. Review of Resident #9's medical record, dated [DATE], revealed the resident had a PHQ-9 score of fifteen (15), which indicated moderate severe depression. Review of the MAR for Resident #9, revealed the resident's physician did not make any changes to his/her medications after being notified of the resident's PHQ-9 score. Interview with LPN #4, on [DATE] at 2:39 PM, revealed he had assisted with the PHQ-9 screening on [DATE] for Resident #9. e. Review of Resident #10's medical record, dated [DATE], revealed the resident had a PHQ-9 score of nine (9), which indicated mild depression. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications and resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 screening on [DATE] for Resident #10. f. Review of Resident #11's medical record, on [DATE], revealed the resident had a PHQ-9 score of thirteen (13), indicating the resident was moderately depressed. Review of the MAR, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SSD, on [DATE] at 10:56 AM, revealed she had completed the PHQ-9 screening on [DATE] for Resident #10. 3. Interview with the Director of Nursing (DON), on [DATE] at 10:29 AM, revealed she notified the physician for Resident's #6, #7, #8, #9, #10 and #11 to review the residents' current medication regimen for the residents assessed to have depression. She revealed there were no additional or new orders provided by the physician. 4. Interview with the Director of Nursing, on [DATE] at 10:29 AM, revealed she reviewed the six (6) residents records that flagged for depression to ensure an applicable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed she completed this on [DATE]. 5. Interview with the Director of Nursing (DON), on [DATE] at 10:29 AM, revealed she reviewed the care plans for the six (6) residents who flagged for depression on the PHQ-9. She stated she ensured the care plans were current to the residents' diagnosis. The DON stated she completed this on [DATE]. Further interview, on [DATE] at 10:29 AM, revealed she assigned future PHQ-9 assessments to the SSD and the Unit Manager. Interview with the Social Service Director (SSD), on [DATE] at 10:56 AM; and the Unit Manager (LPN #4), o [TRUNCATED]

Based on observations, interviews, record review, and facility policy, it was determined the facility failed to ensure the care plan was followed related to the dietary needs of two (2) of eighteen (18) sampled residents. (Resident #66 and Resident #40) Observation during lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes. Review of care plan interventions for both Resident #40 and #60 interventions directed staff to provide diet as ordered. Additionally, Resident #66 meal ticket required (2) two cartons of milk that were observed to not be on the tray of Resident #66 during meal service. The Findings include: Interview on 05/20/2021 at 4:05 PM, with Administrator, revealed the facility did not have policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the Administrator stated the facility followed the standard of practice for care from Center for Medicare and Medicaid (CMS). Review of provided Clinical Standards of Practice, Comprehensive Care Plans Standard of Practice with revision date of 11/2017 revealed; It is the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident will receive the appropriated treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 1. Record review revealed the facility admitted Resident #40 on 06/30/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 to have a brief interview mental status (BIMS) of (3) three which indicated the resident had severe cognitive impairment. Additionally, residents activities of daily living (ADLs) for eating required limited assistance, with no loss of weight in the last (6) six months of 10%. Observation on 05/18/2021 at 11:55 AM, of the Lunch Meal, revealed Resident #40 did not have fortified potatoes on tray per the meal ticket requirement. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #40's Care Plan, dated 04/05/2021, revealed, the resident was at risk for Alteration in Nutrition as evidenced by diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan interventions directed staff to provide diet as ordered, and fortified foods with meals. Review of 05/18/2021 lunch Meal Ticket for Resident #40, revealed Resident to have half cup of fortified mashed potatoes. However, the potatoes was not on the meal tray per ticket requirement. Interview with CNA #5, on 05/18/2021 at 12:03 PM, revealed she did not notice the fortified potatoes were not on the tray. Interview with Assistant Director of Nursing (ADON), on 05/18/2021 at 12:00 PM, revealed, Resident #40's tray should contain the fortified potatoes. The ADON stated the kitchen staff were responsible for preparing the tray according to diet orders and staff that delivered trays should ensure it matched to Meal Ticket at time of service. 2. Record review revealed the facility admitted Resident #66 on 12/01/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly 05/04/2021 MDS revealed Resident #66 was cognitively intact with a BIMS of (13) thirteen. In addition, the resident required limited assistance with eating. Interview on 05/18/21 at 12:06 PM, with Resident #66 revealed resident was sitting in front of lunch tray stated where is my milk and tray with no milk on it or fortified potatoes. Observation on 05/18/2021 at 12:06 PM with Resident #66 revealed lunch meal tray with no fortified mashed potatoes or milk visible on tray as required per lunch meal ticket. Review of 05/18/21 lunch meal ticket revealed resident required to have 1/2 cup of fortified mashed potatoes and (8) eight ounces of milk (2 whole milks). Record review of the dietary orders for Resident #66 dated 02/23/21 with ending date of 05/31/21 revealed; dietary order for regular vegetarian diet, consistency thin regular liquids, and vegetarian and fortified foods with all meals. Record review of Resident # 66's care plan with target date of 06/30/2021 revealed, Alteration in nutrition as evidenced by diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66 is to maintain idea/usual body weight X 90 days. Interview on 05/18/21 at 12:07 PM and on 05/20/21 at 9:38 AM with CNA #4 revealed milk and potatoes were not on the meal tray for Resident #66. Additionally, CNA #4 stated that milk is brought to the floor and served on the trays to the resident by staff. Interview on 05/18/2021 at 12:10 PM, and on 05/20/21 at 09:39 AM with ADON revealed the tray did not have the milk or the potatoes, but should be on the tray when served. Additionally, ADON stated there was two (2) instances back-to-back related to the fortified mashed potatoes not being on the meal trays for residents, and milk is served by the nursing staff on the floor, and whomever passes the tray should ensure that the meal ticket requirements are the tray and kitchen should make sure as well. Interview on 05/18/2021 at 12:10 PM and on 05/20/2021 at 3:54 PM with Licensed Practical Nurse (LPN) #4/Unit Manager (UM) #1 revealed he had served Resident #66 tray and stated he just looked and thought he saw the milk and potatoes but guessed he did not. LPN #4/UM #1 stated that dietary checks the ticket and puts on the tray what is supposed to be on the ticket, and the residents have fortified food because the diet is needed probably for weight gain; Additionally, LPN #4/UM #1 revealed all staff is to follow the care plan in the best interest of the resident. Interview on 05/20/2021 at 10:32 AM with Dietician revealed the reason for dietary fortified foods and 8 ounces of milk for Resident #66 is that he/she is on lacto-ovo diet (milk eggs can have things like that to ensure calories),and he/she is a picky eater so did that to ensure additional calories and protein. Dietician stated if on meal ticket should be supplied when asked about fortified food for Unsampled Resident #40 and Resident #66 and milk required per meal ticket for Resident #66. Interview on 05/20/21 at 3:56 PM with ADON revealed that everyone is to follow the care plan due to the care plan being the guide to take care of the residents and their nutrition. Interview on 05/20/2021 at 3:59 PM with Staff Development Coordinator revealed that staff is to follow what is on the care plan for fortified foods and would expect the staff to get what is required on the meal ticket for the residents. Interview on 05/20/2021 at 4:07 PM with Director of Nursing (DON) revealed that she expects staff to follow the care plan in providing care for residents and that the chain of command is to be followed to ensure that care is provided to the resident; everyone follows the residents plan of care.

Based on observation, interview, and Code of Federal Regulations (CFR) 483.45(g) review, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for one (1) of the facility's two (2) medication rooms. On [DATE], observation of the medication room on the 200 Hall revealed a [MEDICATION(S)] (insulin) pen and Bromfed (antihistamine, cough suppressant, decongestant) liquid were opened. However, the drugs were not dated when opened. Interview with the Administrator revealed the facility did not have a policy for storage and labeling of drugs and biologicals. The findings include: Review of the CFR titled, 483.45(g) Labeling of Drugs and Biologicals and §483.45(h) Storage of Drugs and Biologicals revealed the facility staff should date the label of any multi-use vial when the vial was first accessed and access the vial in a dedicated medication preparation area. If a multi-dose vial had been opened or accessed, the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. On [DATE] at observation of the Medication Room on the 200 Hall, revealed a [MEDICATION(S)] (insulin) pen and Bromfed (antihistamine, cough suppressant, decongestant) liquid were opened. However, the drugs were not dated when opened. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:05 PM, revealed the date should be written on any drug and/or biological when opened to ensure drugs and biologicals weren not stored past the use by date. Continued interview revealed the facility's policy was to date all drugs and biologicals when opened. LPN #2 stated it was important to write the date opened on the drug so others would know date of expiration. Interview with the Director of Nursing (DON), on [DATE] at 4:47 PM, revealed the [MEDICATION(S)] insulin pen and Bromfed liquid should have been dated when opened. Continued interview revealed staff who opened drugs and/or biologicals were responsible to date and initial the container. The DON stated dating drugs after opening was done to ensure residents were not given expired or outdated drugs. Interview with the Administrator, on [DATE] at 4:49 PM, revealed the facility did not have a policy for labeling and storage of drugs and biologicals. Continued interview revealed the facility followed Federal and State guidelines for labeling and storage of drugs and biologicals.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide a well-balanced diet to meet the dietary needs of for two (2) of eighteen (18) sampled residents, Resident # 66 and #40 During lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes per the Meal Ticket, physician order, or care plan. Additionally, Resident #66's Meal Ticket required (2) two cartons of milk to be provided, however, they were not on Resident #66's tray. The Findings include: Interview on 05/20/2021 at 4:05 PM, with the Administrator, revealed the facility did not have for policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the facility does follow the standard of practice for care from Center for Medicare and Medicaid (CMS). Review of the Comprehensive Care Plans Standard of Practice, with revision date of 11/2017, revealed it was the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident would receive the appropriated treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 1. Record review revealed the facility admitted Resident#40 on 06/30/2020, with diagnoses to include Dementia with Behavioral Disturbance, Need for Assistance with Personal Care, Other Symptoms and Signs involving Cognitive Functions and Awareness, Age-Related Nuclear Cataract, Blepharoconjunctivitis (inflammation of the transparent covering of the eye due to bacterial or [CONDITION(S)] infection)/Blepharitis Bilaterally (eye-lid drooping), and Retinal Vascular Appearance bilaterally. Review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief interview mental status (BIMS) of (3) three indicating severe cognitive impairment, and required limited assistance for eating related to activities of daily living (ADLs). Additionally, per K0300 of MDS the resident had not lost weight in month or 10% of weight loss in the last (6) six months. Observation on 05/18/2021 at 11:55 AM, revealed Resident #40's tray did not have fortified potatoes on tray per the Meal Ticket requirement. Review of Resident #40's Physician Orders, revealed and order with a start date of 01/05/2021 and ending date of 05/31/2021 which ordered staff to provide a regular consistency diet with thin liquids, fortified foods with meals. Review of Resident #40's Plan of Care, dated 04/05/2021, revealed the resident was at risk for Alteration in Nutrition, as evidenced by diagnosis of Dementia which required cueing/assistance with all aspects of activities of daily living; with treatment/intervention to provide diet as ordered, and resident ate independently staff would provide assistance as needed, and would provide fortified foods with meals. Review of 05/18/2021 lunch Meal Ticket for Resident #40, revealed Resident to have half cup of fortified mashed potatoes. Interview on 05/18/2021 at 12:03 PM, with Certified Nursing Assistant (CNA) #5, revealed she served the tray for Resident #40 but did not notice the fortified potatoes were not on the tray. Interview on 05/20/2021 at 10:32 AM, with Dietician, revealed the reason for fortified foods was to maintain or increase resident weight. The Dietician stated the ordered meal requirements should be served on the tray Interview on 05/18/2021 at 12:00 PM, with Assistant Director of Nursing (ADON), revealed Resident #40's tray did not have the fortified potatoes as indicated on the Meal Ticket. The ADON stated when trays were passed staff should ensure the items on the tray matched the Meal Ticket prior to serving to the resident. In addition, the kitchen staff should ensure the required food items were on the tray as well. 2. Record review revealed the facility admitted Resident #66 on 12/01/2020 with diagnoses of Unspecified- Dementia with Behavioral Disturbance, [CONDITION(S)] [CONDITION(S)], Type II Diabetes Mellitus, Generalized Anxiety Disorder, Chronic [CONDITION(S)], Chronic Kidney Disease, and Unspecified Systolic Congestive Heart Failure. Review of the MDS dated [DATE], revealed Resident #66 had a BIMS of (13) thirteen indicating the resident to be cognitively intact. Additionally, Resident #66 required limited assistance with eating concerning his/her ADLs and had not had a weight loss of 10% in (6) six months. Record review of the dietary orders for Resident #66, dated 02/23/2021 with ending date of 05/31/2021, revealed a dietary order for a regular vegetarian diet, with thin liquids, and fortified foods with all meals. Observation on 05/18/2021 at 12:06 PM, revealed Resident #66's lunch meal did not have fortified potatoes or milk on tray, as required per lunch Meal Ticket. The resident was heard to say where is my milk?. Interview on 05/18/2021 at 12:06 PM, with Resident #66, revealed he/she was missing milk on his/her tray. Review of the 05/18/2021 lunch Meal Ticket, revealed Resident #66 was required to have a half cup of fortified mashed potatoes and (8) eight ounces of milk (2 whole milks). Record review of Resident # 66's Care Plan, with target date of 06/30/2021 revealed, the resident was at risk for Alteration in Nutrition as evidenced by diagnosis of Dementia. The interventions directed staff to adjust for food allergies/intolerance, allow for likes /dislikes, ethnic preferences with diet order, provide diet as ordered and maintain independent eating. Resident #66 was to maintain idea/usual body weight times ninety days. Interview on 05/18/2021 at 12:07 PM, and on 05/20/2021 at 9:38 AM, with CNA #4, revealed milk and potatoes were not on the meal tray for Resident #66, and she did not know who provided the resident the tray. Additionally, CNA #4 stated that milk was brought to the floor and served on the trays to the resident by staff. Interview on 05/18/2021 at 12:10 PM, and on 05/20/2021 at 9:39 AM with ADON revealed the tray did not have the milk or the fortified potatoes, but should have been on the tray when served. Additionally, the ADON stated there were two (2) instances back-to-back related to the fortified mashed potatoes not being on the meal trays for residents which was an issue. She stated the milk was served by the nursing staff on the floor and poured into a cup if resident desires, and whomever passed the tray should ensure the meal ticket requirements were on the tray and kitchen staff should ensure as well. Interview on 05/18/2021 at 12:10 PM, with Licensed Practical Nurse (LPN) #4/Unit Manager (UM) #1, revealed he had served Resident #66 tray and stated typically opened the lid of the plate and checked to ensure the resident was getting everything he/she was supposed to according to the Meal Ticket. Additionally, LPN #4/UM #1, stated he just looked and thought he saw the milk and potatoes but guessed he did not. LPN #4/UM #1 stated that dietary checked the Meal Ticket to ensure the ordered dietary requirments were on tray. He stated the residents had fortified food because that diet was needed and was probably for weight gain. Interview on 05/18/2021 at 12:20 PM, with Dietary Aide (DA) #1, revealed the resident tray was checked by the kitchen staff prior to sending to the unit. The DA was not sure how the fortified foods had been missed. Additionally, the Dietary Aide #1 stated the milk was taken to the unit for the nursing staff to pass out with the meal trays. Interview on 05/20/2021 at 10:32 AM, with Dietician, revealed the reason for dietary fortified foods and eight ounces of milk for Resident #66 was that he/she was on lacto-ovo diet (milk/eggs). The Dietician stated the resident was a picky eater so the diet was to ensure additional calories and protein. The Dietician stated the ordered meal requirements should be on served on the tray. Interview on 05/20/2021 at 4:07 PM with Director of Nursing (DON) revealed that she expected staff to follow the care plan in providing care for residents related to ordered meal requirements to ensure nutrition needs were met.

Based on interview, record review, facility policy review, and facility fax information, it was determined the facility failed to report an allegation of abuse to the State Survey Agency no later than two (2) hours after the allegation was received for one (1) of three (3) sampled residents (Resident #1) On 10/10/19 at approximately 1:00 PM, the Director of Nursing (DON) was made aware of Resident #1's allegation of abuse; however, the facility failed to notify the State Survey Agency within the two (2) hour timeframe in accordance with facility policy. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 05/18/19 revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two (2) hours after the allegations is made. Record review revealed the facility admitted Resident #1 on 08/04/19 with diagnoses, which included Type 2 Diabetes Mellitus, Major [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Admission Minimum Data Set (MDS) assessment, dated 08/04/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated this resident was interviewable. Interview with Resident #1's family member, on 10/15/19 at approximately 10:30 AM revealed she visited Resident #1 on 10/10/19 around noon and Resident #1 told her that Certified Nurse Aide (CNA) #1 touched him/her inappropriately while providing incontinent care. Family member #1 stated she informed Registered Nurse (RN) #1 about the incident. Interview with RN #1 on 10/16/19 at approximately 10:35 AM, revealed on 10/10/19 at 12:30 PM, she was made aware of Resident #1's allegation that CNA #1 touched the resident inappropriately during incontinent care. RN #1 stated she called the Director of Nursing (DON) and reported the allegation to her immediately. Interview with the Social Services Director on 10/16/19 at approximately 9:50 AM revealed the DON made her aware of Resident #1's allegation of abuse on 10/10/19 around 1:00 PM. However, review of the facility fax confirmation of the Abuse allegation notification to the Office of Inspector General, dated 10/10/19, revealed the fax was sent by the facility and received by the Office of Inspector General on 10/10/19 at 5:56 PM (approximately five (5) hours after the allegation was received by Administration). Interview with the DON, on 10/17/19 at 11:00 AM revealed the two- hour period did not begin until after the abuse coordinator was notified. The DON also stated the facility tried several times to notify OIG via fax but the fax would not go through. However, the only documentation the DON could provide showing the earliest fax attempt was the fax sent at 5:56 PM on 10/10/19. Interview with Administrator on 10/17/19 at 11:00 AM revealed the two (2) hour notification timeframe does not start until two hours after the Abuse Coordinator was notified; and, after the perpetrator was made aware of the allegation and suspended pending the outcome of an investigation. The Surveyor informed the Administrator that the two-hour period for reporting to the Survey Agency starts the minute the facility becomes aware of the allegation.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident was free from abuse, neglect and corporal punishment of any type by anyone for one (1) of twenty-five (25) sampled residents (Resident #67). Interviews with Resident #67 on 02/12/19 revealed during the night shift on 02/11/19, he/she asked a staff member to put a pillow behind his/her head and the staff member threw the pillow at him/her, hitting him/her in the face. Resident #67 stated the staff threatened the resident that he/she would remain in the facility longer for asking for help. Resident #67 stated this treatment caused him/her to be fearful and sad. In addition, the resident was sent to the hospital due to increased anxiety after attempting to identify the alleged perpetrator by looking at pictures of staff and staff walking by his/her room. The findings Include: Review of the facility policy titled, Abuse Prohibition Standards of Practice, last revised (MONTH) (YEAR), revealed each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. The following standards of practice will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Record review revealed the facility admitted Resident #67 on 01/24/19 with [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set (MDS) assessment, dated 02/10/19, revealed the facility assessed Resident #67's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated this resident was cognitively intact and interviewable. Interview with Resident #67 on 02/12/19 at approximately 9:35 AM revealed Resident #67 reported that on the previous evening during the night shift the staff member that came into his/her room and assisted him/her was very mean and rude to him/her. Resident #67 stated he/she asked the staff member to put a pillow behind his/hr head and the aide threw the pillow at him/her hitting him/her in the face with the pillow. Resident #67 further stated the staff member told him/her in a very mean tone you're gonna have to learn to do this yourself. Resident #67 revealed the staff member also told him/her that she was going to put a note in the resident's chart reporting that the resident asked for help and that would ensure the resident remained at the facility longer. Resident #67 stated the incident made him/her feel fearful and sad. Resident #67 stated he/she did not know the name of the staff member that threw the pillow at him/her but described the staff as being female with long brown hair who wears glasses. At the end of the conversation, Resident #67 asked the Surveyor for some help adjusting his/her pillow behind his/her head. Surveyor informed an aide that Resident #67 needed some assistance and Surveyor observed the aide adjust the pillow behind Resident #67's head and observed the resident's face which appeared sad and on the verge of tears. Surveyor heard Resident #67 ask the aide, Am I gonna get written up? The aide told Resident #67 no, why would you get written up? Resident #67 stated the aides tell me I'm gonna get written up every time I ask them to help me and that I will have to stay at the facility even longer. Interview with family member #1 on 02/12/19 at approximately 9:55 AM who was Resident #67's roommate's son revealed he had observed many of the aides having attitudes and talking rough with a lot of the residents and that it takes staff a long time to respond to call lights. Family member #1 stated some of the aides don't like to help Resident #67 and he has assisted Resident #67 in the past but the facility informed him that he was not allowed to do that. Family member #1 stated he knows Resident #67 was supposed to do a lot on his/her own but Resident #67 only asked for help from staff when he/she really needed it. On 02/12/19 at approximately 10:10 AM, Surveyor informed the Administrator and Director of Nursing (DON) of the allegation of abuse made by Resident #67 and the description of the staff member. The Administrator and DON both reported they had no prior knowledge of the allegation and were not aware of the alleged incident. The Administrator and DON stated there was no staff employed at the facility that fit that description. Review of Nursing Progress Notes dated 02/07/19 at 9:06 PM and interview with the DON on 02/12/19 at approximately 10:10 AM revealed Resident #67 made false allegations in the past when he/she reported to one staff member that he/she did not receive night time medications until 8:30 PM and reported to another staff member that he/she did not receive his/her medications until 10:00 PM. Review of Resident #67's Comprehensive Care Plan revealed the resident was care planned for making these false allegations; however, the facility was unable to provide documentation the facility completed an Investigation regarding the claims made by Resident #67 to try to determine if the allegations were false. Further interview with family member #1 on 02/12/19 at 10:15 AM outside Resident #67's room revealed Therapy wanted Resident #67 to do things by him/herself but sometimes Resident #67 needs help and staff won't provide it to him/her. Family member #1 stated his parent (Resident #67's roommate) told him that neither resident gets much help at night and staff do not like them on the call light at night. At the end of the conversation Surveyor observed Resident #67's door open and the Administrator, DON and Assistant Director of Nursing (ADON) exit. Interview with Resident #67 on 02/12/19 at approximately 10:30 AM revealed the Administrator and the DON just came into his/her room and they brought a boy with them this time. Resident #67 stated the Administrator told him/her the incident that was reported did not happen to you. Resident #67 revealed the Administrator and DON told him/her the nurse or aide did not hit him/her in the face with anything and that he/she was making the story up. Resident #67 stated she was more afraid he/she would not be able to leave the facility anytime soon. Interview with Administrator, DON and team leader on 02/12/19 at approximately 11:00 AM revealed the Administrator reported she, along with the DON and ADON interviewed Resident #67 in regards to the alleged allegations. The Administrator stated Resident #67 reported the nurse or aide did not hit him/her in the face with the pillow but the nurse or aide tossed the pillow towards him/her after he/she requested a pillow. The Administrator revealed they spoke with Resident #67's roommate's son and he reported he never saw staff in the room assisting Resident #67 before leaving, and he observed staff being very encouraging to Resident #67 to try and do things on her own in regards to therapy, and that Resident #67 was very needy. The DON also stated Resident #67 reported having a hole in his/her mattress and they checked the mattress and there was clearly no hole implying that Resident #67 was confused and made false claims. Interview with Resident #67 on 02/12/19 at approximately 11:30 AM in regards to the conflicting statements the Administration reported in regards to their questioning of Resident #67 revealed when Surveyor asked Resident #67 to explain what happened with the nurse or aide and the pillow to ensure Surveyor understood the scenario correctly. Resident #67 stated the nurse or aide threw the pillow at him/her and hit him/her in the face. Surveyor asked Resident #67 if he/she reported to the Administrator and DON that the staff member hit him/her in the face and Resident #67 replied yes, I told them the nurse or aide threw the pillow and it hit me in the face. Surveyor asked Resident #67 if her roommate's son was in the room when the incident occurred and he/she replied no, he had already gone home before it happened. Surveyor asked Resident #67 if he/she reported to the Administrator and DON that his/her roommate's son was present during the incident and Resident #67 stated no, he/she did not. Surveyor asked Resident #67 if she reported having a hole in his/her bed and he/she stated he/she did not have a hole in his/her bed but an indention in the middle of the bed where the mattress was sunk in and it was uncomfortable to sleep on. On 02/12/19 at approximately 1:15 PM Surveyors told the Administrator the Surveyors had some concern since Administrator's interviews with Resident #67 and Surveyors interviews with the resident seemed to be conflicting statements and the Surveyors would like to Interview Resident #67 in regards to the allegation with the Administrator present. The Administrator stated she spoke with Resident #67's doctor and due to Resident #67's increased anxiety in relation to the allegations and questioning they felt that Surveyors should wait until the next day to talk with Resident #67 anymore in regards to the allegations. Interview with Resident #67's Physician on 02/12/19 at approximately 3:20 PM revealed he never actually spoke with the Administrator but he did receive a fax from the facility stating Resident #67 had increased anxiety and Resident #67 was unable to do anything for herself as a result of the anxiety. Resident #67's Physician stated the only recommendation he made was for the facility to schedule a Psychological evaluation for Resident #67. Resident #67's Physician further revealed he did not feel like there was any reason why Surveyors could not speak with and interview Resident #67 in regards to the allegations. Interview with Resident #67 on 02/12/19 at 4:18 PM with the Administrator present revealed Resident #67 stated the nurse or aide told him/her there were forty-eight (48) other residents she had to assist and the resident had no business being on the call light. Resident #67 stated the nurse or aide told him/her I'm going to tell you right now you're going to have trouble getting out of here. Resident #67 stated he/she asked the nurse or aide to get him/her a pillow and the nurse or aide tossed it at him/her and the pillow hit him/her in the face. The resident stated all staff look the same but the nurse or aide was wearing the colors teal/blue. Resident #67 stated she told his/her roommate's son about the incident the next morning. Resident #67 stated there is a blonde staff member who tells him/her that he/she can do it him/herself and does not offer assistance. Resident #67 stated he/she only wants help when he/she needs help. Record review revealed on 02/12/19 when Administrator had initially advised Surveyors against further interviews with Resident #67 due to concerns over the resident's increased anxiety that Resident #67 had to be taken to the Medical Center of Bowling Green for emergency medical attention for concerns of Anxiety and stress reaction. The Administrator admitted Resident #67's hospital visit occurred after the Administrator showed photos of the alleged perpetrator and had potential perpetrators walk pass Resident #67's door for Resident #67 to identify. Interview with Resident #67 on 02/14/19 at approximately 8:20 AM revealed that girl came into his/her room last night (02/13/19) with LPN #4. Resident #67 stated he/she recognized her and that her name was SRNA #3. Resident #67 stated SRNA #3 was the aide that threw the pillow at him/her and hit him/her in the face. Resident #67 stated he/she does not want SRNA #3 or LPN #4 back in his/her room anymore because it made him/her feel uncomfortable. On 02/14/19 at 8:30 AM with another Surveyor present the Administrator was informed Resident #67 had identified the alleged perpetrator as SRNA #3. The Administrator stated Resident #67 also reported to her that he/she had identified the alleged perpetrator as SRNA #3 but Administrator stated SRNA #3 has blonde hair. The Administrator was also informed that Resident #67 requested that SRNA #3 and LPN #4 not be allowed to provide him/her care. The Administrator stated Resident #67 made the same request to her but she explained to Resident #67 that was not possible due to potential safety concerns. Attempted interview on 02/15/19 at approximately 10:40 AM with SRNA #3 was unsuccessful as the number provided by Administrator was disconnected. Interview with DON on 02/15/19 at approximately 1:55 PM revealed when they interviewed Resident #67 in regards to the alleged allegation she, along with Administrator acted out the alleged incident in front of the resident to ensure they understood exactly what happened. The DON stated the resident stated the nurse pitched the pillow at him/her but resident was unable to catch the pillow and that is why the pillow hit resident in the face. Surveyor asked the DON if the resident reported the pillow did hit him/her in the face and DON stated yes, but the nurse did not mean for the pillow to hit him/her in the face. Surveyor asked DON why Administrator and DON reported to Surveyor and Lead Surveyor that Resident #67 stated to them specifically that the pillow never actually hit Resident #67 in the face. The DON stated she did not recall that being stated. Interview with Administrator on 02/13/19 at approximately 10:00 AM revealed she in accordance with the facility have a zero tolerance in regards to abuse and that she takes the allegations very seriously and that it was her expectation that all staff treat residents respectfully and residents they feel safe in the facility.

Based on interview, record review and review of facility policy, it was determined the facility failed to prevent further potential abuse, or mistreatment while an investigation was is in progress by failing to suspend the alleged perpetrator for one (1) of twenty-five (25) sampled residents (Resident #67). On 02/12/19, Resident #67 alleged he/she was abused by staff on the night shift on 02/11/19, but Resident #67 was unable to identify the staff by their name. On 02/14/19, Resident #67 stated the staff came into his/her room on the evening of 02/13/19 and he/she identified the staff as State Registered Nurse Aide (SRNA) #3. On the morning of 02/14/19, Resident #67 and Surveyors reported this information to the Administrator; however, the Administrator failed to suspend or remove SRNA #3 from care while the allegation was investigated, The findings include: Review of facility policy titled, Abuse, Neglect, Or Misappropriation of Resident Property Policy, last revised 03/10/17, revealed under section VI. Protection, in order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done; the alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation. Record review revealed the facility admitted Resident #67 on 01/24/19 with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment, dated 2/10/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a fifteen (15), which indicated this resident was cognitively intact and interview able. Interview with Resident #67 on 02/12/19 at approximately 9:35 AM revealed Resident #67 reported that on the previous evening (02/11/19), during the night shift, the aide that came into his/her room and assisted him/her was very mean and rude to him/her. Resident #67 stated he/she asked the aide to put a pillow behind her/his head and the aide threw the pillow at him/her hitting him/her in the face with the pillow. Resident #67 further stated the side told him/her in a very mean tone your gonna have to learn to do this yourself. Resident #67 revealed the aide also old him/her that she was going to put a note in the resident's chart reporting that the resident asked for help and that will ensure the resident remained at the facility even longer. Resident #67 stated the incident made her/him feel very fearful and sad. Resident #67 stated he/she did not know the name of the staff member that threw the pillow at him/her but described the aide as being female with long brown hair who wears glasses. On 02/12/19 at approximately 10:10 AM the Administrator and Director of Nursing (DON) were informed of the allegation of abuse made by Resident #67 and the description of the staff member. The Administrator and DON stated there was no staff employed at the facility that fit that description. Further interview with Resident #67 on 02/14/19 at approximately 8:20 AM revealed the girl who threw the pillow at him/her that hit him/her in the face came into his/her room on the night of 02/13/19 and she recognized her and she was SRNA #3. On 02/14/19 at 8:30 AM the Administrator was informed Resident #67 had identified the alleged perpetrator as SRNA #3. The Administrator stated that Resident #67 also reported to her that he/she had identified the alleged Perpetrator as SRNA #3 but the Administrator stated SRNA #3 has blonde hair. Interview with Administrator on 02/15/19 at 1:55 PM revealed the Administrator did not suspend or remove SRNA #3 because Administrator stated she did not feel like SRNA #3 was credibly identified as a perpetrator. The Administrator stated she investigated SRNA #3 and ruled her out as a potential perpetrator. The Administrator revealed SRNA #3 was not suspended or removed from the schedule prior to her being ruled out as a potential perpetrator. The Administrator stated on the evening of 02/12/19 after Surveyors had left for the day she showed Resident #67 several photos of different staff members and she also had staff members walk past Resident #67's door for Resident #67 to look at and Resident #67 did not identify SRNA #3 or any other staff as the alleged perpetrator. The Administrator stated she would show the resident the photos again in front of us to show that SRNA #3 was not the staff the resident identified. On 02/15/19 at approximately 3:15 PM, in the presence of Surveyors, the Administrator informed Resident #67 that he/she would be shown several photos to see if he/she recognized the staff member was the person who struck him/her in the face with a pillow. The Administrator showed the resident a photo of the DON and the resident stated that was not the alleged perpetrator. The Administrator then pulled up a photo of SRNA #3 and the resident identified the person in the photo as the person that Resident #67 reported threw the pillow and hit Resident #67's face.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure food was Stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on 02/12/19, revealed open, unsealed foods being stored in the freezer, dirty kitchen equipment and staff sanitation concerns. Review of Census and Condition dated 02/12/19 revealed eighty-two (82) of eighty-six (86) resident receive there meals from the kitchen. The findings include: 1. Review of facility policy titled Food Storage: Cold Foods, revised 4/2018, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the kitchen on 02/12/19 at 09:29 AM, revealed in the three (3) door freezer multiple break apart beef steak slices were laying in the freezer open to air uncovered with no wrapping or container in place and a plastic bag of bread rolls were present with no labeling or dating noted on the bag. 2. Review of facility policy titled Cleaning and Sanitizing, not dated, revealed surfaces that come in contact with food, must be cleaned and sanitized after each use. Observation of the kitchen on 02/12/19 at 09:35 AM, revealed the kitchen's manual can opener had a build up of black moist material on cutting edge and surrounding area. Interview with the Dietary Manager on 02/12/19 at 9:40 AM, revealed all foods being stored in the refrigerators and freezers should be covered, sealed completely with a label and date present. She stated she expected staff to clean the manual can opener after each use to prevent any build up of material. 3. Review of facility policy titled Handwashing Procedure for Dining Services, not dated, revealed after an employee blows their nose, coughs, sneezes, touches their hair, face or clothes the are required to perform hand hygiene. Observation of the kitchen on 02/12/19 at 11:12 AM, revealed during lunch meal trayline observation of staff, Dietary Aide #1 was observed grabbing bowls of dessert for residents' lunch trays while placing her thumb on the inside area of the bowls after she had been licking her thumb to separate meal ticket slips to review. Interview with Dietary Manager on 02/12/19 at 11:16 AM, revealed staff should not be licking their thumbs then handling dishes. She stated this was a sanitation and infection control issue.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident care plan was reviewed and revised by the interdisciplinary team ongoing with any changes pertinent to the residents' care needs, for five (5) residents (Residents #20, #21, #32, #36, and #71), in the selected sampled of twenty-five (25). Resident #32 had a history of [REDACTED]. He/she was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Resident #20 had an appointment for cataract surgery on 02/19/18. However, the resident refused to go to the appointment stating I'm not having surgery. The comprehensive care plan was not updated to reflect the resident's preferences related to cataract surgery. Residents #21, #36, and #71 have all had multiple falls in the facility over the course of the last six (6) months. However, the comprehensive care plan does not reflect any new updates or new interventions being implemented by the interdisciplinary team after any of the falls to potentially prevent any future falls from occurring. The findings include: Review of the facility policy titled, Comprehensive Care Plans, Standard of Practice, last revised November, (YEAR), revealed it is the practice of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her rights to refuse treatment. Interview with the Administrator, on 03/01/19 at 2:14 PM, revealed the facility does not have a policy that specifically addressed Care Plan Timing and Revision. The Administrator stated the facility followed the RAI guidelines and as needed. 1. Record review revealed the facility admitted Resident #32 on 01/26/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 12/26/18, revealed the facility did not complete the Brief Interview for Mental Status (BIMS) score. The resident had long-term and short-term memory impairment with severely impaired cognition, which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total care with activities of daily living (ADLs) and had an indwelling urinary catheter. Review of the Nurse's Progress notes, dated 09/08/18, revealed Resident #32 was hospitalized with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, not dated, revealed Resident #32 had alteration in elimination as evidenced by incontinence of bowel and foley catheter, history of [MEDICAL CONDITION], [DIAGNOSES REDACTED]. However, the problems listed did not include a history of UTI [MEDICAL CONDITION]. Approaches included report changes to characteristics of urine such as color, odor, and sediment. There was no documented evidence the facility assessed for signs and symptoms of infection or discomfort related to the catheter. Interview with Registered Nurse (RN) #2/MDS Coordinator, on 02/15/19 at 12:33 PM, revealed she was responsible for updating the care plan to reflect the [DIAGNOSES REDACTED]. RN #2 stated the care plan should have been updated, but it was overlooked. Interview with the Director of Nursing (DON), on 02/15/19 at 2:10 PM, revealed she did not think the care plan needed to reflect the [DIAGNOSES REDACTED]. However, the resident had a [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #20 on 07/13/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Review of the Departmental Note, dated 01/22/19 at 4:07 PM, revealed Resident #20 had an appointment with the Ophthalmologist on 02/19/18 at 1:00 PM. However, review of the Twenty-four (24) Hour Report, dated 02/19/18, under the 10:00 PM to 6:00 AM shift remarks, revealed the resident refused to go to the MD appointment. There was no documented evidence of an attempt to reschedule another appointment. Review of the Comprehensive Care Plan, dated 07/25/16, revealed Resident #20 was at risk for visual deficit as evidenced by resident wearing glasses, and will wear other residents' glasses as well. There was no documented evidence the resident refused cataract surgery on 02/19/18. Three (3) attempts to contact RN #2 (MDS Coordinator) for a post-survey interview, on 02/22/19, who was responsible for updating care plans, was unsuccessful. Interview with the DON, on 02/15/19 at 2:10 PM, revealed Resident #20 had an appointment with the surgeon, but refused to go. The DON stated it is the resident's right to refuse to go to appointments. The DON was unable to provide any further information regarding attempts to reschedule the appointment. 3. Record review revealed the facility admitted Resident #36 on 12/17/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/03/19, revealed the facility assessed the resident's BIMS score as a three (3), which indicated the resident was not cognitively intact and was non-interviewable. Review of the Comprehensive Care Plan, dated 01/16/18, revealed the resident was at risk for injury related to a history of falls, and the resident had an injury resulting in a left [MEDICAL CONDITION] related to a [DIAGNOSES REDACTED]. Additional review of the care plan revealed there had been no updates or revisions to the care plan after falls which occurred in the facility. Review of the Falls Investigation Report, dated 01/04/19, 01/07/19 and 02/11/19, revealed the resident had falls in the facility. Further review of the Comprehensive Care Plan revealed there was no evidence revisions were made in regard to any of the resident's falls. 4. Record review revealed the facility admitted Resident #21 on 06/15/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 09/05/18, revealed he/she had a BIMS score of Zero Zero (00), which indicated the resident was not cognitively intact and was non-interviewable. Review of the Comprehensive Care Plan, dated 01/02/19, revealed the resident was care planned for injury related to a history of falls, related to cognition, impaired gait and mobility, resident continues with unsafe transfers and ambulation, and decreased safety awareness. Review of the Falls Investigation report, dated 08/22/18 and 11/23/18, revealed the resident had falls in the facility. Further review of the Comprehensive Care Plan revealed no evidence revisions were made in regard to any of the resident's falls. 5. Record review revealed the facility admitted Resident #71 on 03/28/11 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/14/18, revealed he/she had a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of the Comprehensive Care Plan, dated 05/02/14, and revised 12/19/18, revealed the resident was at risk for injury related to falls, extensive assistance when fatigued, muscle weakness, confused at times, and a history of falls at home. Review of the Falls Risk Assessment revealed a fall occurred on 08/20/18. Further review of the care plan revealed no evidence the care plan was revised after the fall occurred. Interview with the MDS Coordinator, on 02/15/19 at approximately 12:18 PM, revealed her expectation was that new interventions be updated and followed per the care plan. She stated it was the Nursing Department's job to update the Care Plans with immediate interventions, and that updated interventions be reflected on the current Care Plans. She stated she was instructed by staff not to put revision dates on the care plans. Interview with the DON, on 02/15/19 at approximately 2:15 PM, revealed the facility's software did not allow staff to show revision dates on the care plans. Further interview with the Administrator, on 02/15/19 at approximately 2:15 PM, revealed her expectations were that care plans be updated within 24 to 48 hours, depending on the weekday, after new interventions were identified.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat one (1) of twenty-five (25) sampled residents with respect and dignity and care for the resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident's individuality (Resident #36). Resident #36 was resistive to care when staff identified the resident had food on his/her shirt and face after eating his/her meal; however, staff failed to provide a second attempt to clean the resident's face and change shirt for over and hour later and failed to follow facility protocol of having another staff attempt to clean the resident. The findings include: Review of the facility policy titled Resident Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The resident has the right to be treated with respect and dignity. Record review revealed the facility admitted Resident #36 on 12/17/18 with [DIAGNOSES REDACTED]. Review of Admissions Minimum Data Set (MDS) assessment, dated 01/03/19, revealed the facility assessed Resident #36's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated this resident was interviewable. Observation on 2/12/19 at approximately 1:45 PM revealed Resident #36 was lying on back in bed. Resident #36's shirt was completely covered in food and crumbs. Interview was attempted with Resident #36 as to why his/her shirt had so much food on it but Resident #36 was unable to verbalize anything. Further observation revealed there was no food tray present in Resident #36's room or anything to indicate Resident #36 was eating or had just finished eating. Observation on 02/12/19 at approximately 1:50 PM revealed Resident #36 was still lying on is/her back in bed with his/her shirt completely covered in food and crumbs. Interview was attempted with Resident #36 as to why he/she had so much food on his/her shirt but Resident #36 was unable to verbalize anything. Interview on 02/12/19 at approximately 2:04 PM with State Registered Nurse Aide (SRNA) #6 revealed she picked up Resident #36's tray today (02/12/19) after lunch and she asked Resident #36 if he/she was finished with his/her food. She stated when she attempted to clean Resident #36's face and change his/her shirt the resident would not allow her to clean his/her face or change the shirt. SRNA #6 revealed it was the normal process to ask a resident if staff can clean them or change their clothes. SRNA #6 stated she reported the incident to the DON and waited about forty-five (45) minutes to an hour before trying to go back into Resident #36's room again and trying to clean him/her again. SRNA stated she did not remember the time that she attempted to get Resident #36's tray and clean him/her, but tray pick up was usually between 12:30 and 1:00 PM daily. SRNA #6 revealed when she reported it to the DON, the DON instructed her to wait a while and then go back and check on Resident #36. SRNA #6 stated the DON did not attempt to intervene with the resident and did not have another staff attempt to assist SRNA #6 in changing Resident #36's clothes or clean his/her face. Interview on 02/13/19 at approximately 9:20 AM with SRNA #7 revealed during tray pick up they knock on the resident's door and ask the resident if they have finished eating. SRNA #7 stated if the resident was not finished they leave and come back and check again. SRNA #7 revealed if she observed the resident's clothes were soiled she would change the resident's clothes but if the resident was resistive, staff protocol was to immediately notify the charge nurse on duty. SRNA #7 stated if a resident was covered in food and staff was having an issue with the resident allowing them to change their clothes, staff would wait a little before another attempt but leaving a resident in food for thirty (30) minutes before a 2nd attempt was too excessive. SRNA #7 stated she has provided care to Resident #36 and is familiar with his/her demeanor. SRNA #7 stated Resident #36 is usually reserved but Resident #36 is more aware of what is going on around him/her than he/she communicates. SRNA #7 revealed for the most part Resident #36 allows staff to change his/her clothes if needed. SRNA #7 stated there are some days Resident #36 yells out but Resident #36 does well with staff. SRNA #7 stated if Resident #36 appeared to be resistive she would redirect Resident #36 and the resident does well with most requests. SRNA #7 stated she has received training by the facility on how to care and interact with a resistive or combative resident. Interview on 02/13/19 at approximately 9:40 AM with SRNA #8 revealed during tray pick up she goes to each resident's room and asks them if they are finished eating. SRNA #8 stated if the resident states yes, then she offers assistance to the resident to clean them up and change their shirt if the resident has food on them. SRNA #8 revealed she always kneels down and will make sure she is face to face when speaking to a resident to make them feel more comfortable. SRNA #8 stated nine (9) of ten (10) residents usually allow staff to assist. SRNA #8 stated if a resident is resistive, the protocol was to immediately get the charge nurse on duty to come into the resident's room to offer assistance. SRNA #8 revealed she would continue to check on the resident every ten to fifteen (10-15) minutes maximum and would never allow a resident to just remain in their bed covered in food. SRNA #8 stated she has provided care to Resident #36 and Resident #36 was confused at times but he/she was a sweet heart. SRNA #8 further revealed if Resident #36 becomes confused and resistive, she would calmly explain to Resident #36 what she was trying to do and there usually was no issue. SRNA #8 stated she was not aware of a situation when a SRNA was unable to provide care to Resident #36 when it was needed. SRNA #8 stated she has received training by the facility on how to care and interact with a resistant or combative resident. Interview on 02/13/19 at approximately 9:55 AM with SRNA #9 revealed she knocks on the residents' doors before entering and asks the resident if they are done with their food and then takes the tray if they are finished. SRNA #9 stated if she observes the resident has food on them or soiled clothes she will change their clothes and wash their face. SRNA #9 revealed if the resident was resistant that protocol was to immediately notify the charge nurse on duty and then follow the charge nurses lead on the next steps to take. SRNA #9 stated she has never ran into a situation where a resident would be left for even a period of thirty (30) minutes to an hour covered in food. SRNA #9 further stated she has provided care to Resident #36 and Resident #36 was usually calm and she has never observed a situation in which Resident #36 was resistant and would not allow staff to provide assistance when needed. SRNA #9 stated she has received training by the facility on how to care and interact with a resistant or combative resident. Observation and Interview with Charge Nurse #3 on 02/12/19 at approximately 2:00 PM revealed Resident #36 was still lying in bed on his/her back with his/her shirt covered in food and crumbs. Charge Nurse #3 stated SRNA's were responsible for picking up the trays after lunch and cleaning up the resident's face and/or changing the resident's clothes if the clothing was soiled or if the resident has food or any mess on their face. Charge Nurse #3 revealed the condition in which Resident #36 was left in his/her bed was unacceptable and no resident should ever be left in their bed covered in food. Interview (Post Survey) with the DON on 03/01/19 at approximately 2:00 PM revealed SRNA #6 reported Resident #36 was being combative and would not allow SRNA #6 to change Resident#36's clothes. The DON stated she told SRNA #6 to reapproach Resident #36 at a later time and SRNA #6 went back after about a hour and was able to change Resident #36. The DON revealed residents have the right to refuse to be cleaned and have their clothes changed and that she expected staff to respect residents' right to refuse care. The DON stated protocol for SRNA's dealing with a combative or resistant resident was to notify any nurse on the floor and reapproach resident later.

Based on observation, interview, record review and facility Resident Rights review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents, the right to have reasonable access to visit his/her son at the facility (Resident #48). The findings include: Review of the facility copy of Resident Rights, not dated, revealed the resident has a right to receive visitors of his or her choosing at the time of his or her choosing. Review of the facility document titled, Resident Right - Inform of Visitation Rights/Equal Visitation Privileges, revealed it is the policy of the facility to inform residents and resident representatives of visitation rights and privileges in such a manner to acknowledge and respect resident rights. Further review of the document revealed the procedures that the facility will meet were as follows: 1. Inform each resident (or resident representative, where appropriate) of his or her visitation rights and related facility policy and procedures, including any clinical or safety restriction or limitation on such rights, consistent with the requirements of this subpart, the reasons for the restriction or limitation, and to whom the restrictions apply, when he or she is informed of his or her other rights under this section. 2. Inform each resident of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse (including a same-sex spouse) a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. 3. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation , or disability and 4. Ensure that all visitors enjoy full and equal visitation privileges consistent with resident preferences. Record review revealed the facility readmitted Resident #48 on 04/27/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/19, revealed the #48's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) whish indicated the resident was not interviewable. Interview with the Complainant on 02/11/19 at 12:11 PM, revealed Resident #48's son was not allowed to visit with the resident since he got into an argument with a nurse and the son was told for a period of time. The Complainant stated when the son called the Administrator to see if he could come see the resident, he was told by the Administrator that he could not return to see the resident. The Complainant stated the son could get loud, but would never cause harm to anyone. Observation on General Tour, on 02/12/19 at 10:32 AM, revealed Resident #48 was sitting in wheelchair near the nurses station. When asked by the surveyor, if he/she had visitors, the resident started to tear up and said that one of his/her sons was not allowed to visit. The resident went on to say Administrator and Police, but it was difficult to get further details from the resident. Three (3) unsuccessful attempts to reach Resident #4's son were made on 02/15/19 at 9:30 AM, 10:53 AM and 12:50 PM. Interview with Licensed Practical Nurse (LPN) #2, on 02/15/19 at 9:36 AM, revealed when Resident #48's son came to the nurses station, he was yelling and cursing, and sounded very loud and threatening. LPN #2 stated she did not remember what he was upset about but he would always have an attitude towards staff. LPN #2 stated this was the worse she had ever seen him and she notified the DON and the Administrator who told her she should call the police. She revealed the son was leaving as the police officer was arriving. She stated the resident had never told her the son could not visit and she was not aware of any residents with a visitor restriction. Interview with the facility Administrator, on 02/15/19 at 9:13 AM, revealed the Police Officer told them it was a two (2) year ban for the son to be allowed to come back for visiting. She stated the son is very aggressive and she must protect her residents and staff. She also stated the facility can get the resident a cab to take him/her to their home to ensure visitation, but the sons have declined. Interview with the Complainant, on 02/15/19 at 9:17 AM, revealed the facility has never offered to send the resident to the family home but did say he could come get the resident and take her home for a visit but the son stated they do not have the means to care for the resident, so they have declined. Interview with the Director of Nursing (DON), on 02/15/19 at 2:15 PM, revealed a resident can have visitors as long as every resident and staff are safe. She stated the facility did not set up an onsite, supervised visit for Resident #48's son but did offer to send the resident to the home but could not send staff to assist in the care of the resident. The DON stated, It would be just like going to a doctors office for an appointment. She revealed the family did not request other options for visitation but stated the facility would assist in any way they could. Interview with the Administrator, on 02/15/19 at 2:36 PM, revealed she expected the resident be allowed visits from family as long as the visitors can abide by the policy and be respectful to staff and other residents. She stated that it was a recommendation from the police to not allow the particular son to visit, but that she had the final say.

Based on observation, interview, record review, review of facility policy, and housekeeping inservice training, it was determined that the facility failed to ensure the resident environment was sanitary for one (1) of twenty-five (25) sampled residents (Resident #17). Observation of Resident #17's bathroom on 02/12/19 and on 02/13/19, revealed the commode had dried, crusted fecal matter smeared all over the commode seat and commode bowl in the same areas for the two (2) consecutive days. The findings include: Review of facility policy titled Complete Room Clean Checklist, not dated, revealed the residents' bathrooms were to be cleaned, including the commode, bath tubs, walls and floors. Review of the facility's Housekeeping In-service training for housekeeping employees titled 7-Step Daily Washroom Cleaning, dated 1/1/2000, revealed step five (5) was to clean and sanitized the commode which includes the commode tank, the seat, the bowl and the base. Record review, revealed the facility admitted Resident #17 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 12/17/18, revealed the facility assessed Resident #17's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Observation of Resident #17's bathroom on 02/12/17 at 2:02 PM, revealed there was dried, crusted fecal matter smeared all over the commode seat and commode bowl. Observation of Resident #17's bathroom on 02/13/19 at 10:35 AM, revealed there was dried, crusted fecal matter smeared all over the commode seat and commode bowl. Interview with Resident #17 on 02/12/19 at 2:00 PM, revealed he/she had been upset because his/her commode was very dirty with bowel movement all over it and nobody will clean it. Interview with Resident #17 on 02/13/19 at 10:34 AM, revealed his/her commode was still filthy and he/she was upset because he/she felt like the commode was to dirty to even use and nobody will clean it. Interview with Medical Records Clerk on 02/15/19 at 10:07 AM, revealed she was the department head at the facility that had Resident #17's room as part of her section of residents' rooms to check each morning for cleanliness. She stated she had noticed Resident #17's commode was soiled on 02/12/19 and on 02/13/19 and had told someone in housekeeping about the commode being dirty and needing cleaning. She revealed she would have expected housekeeping to have cleaned the commode due to it being very soiled. Interview with Housekeeping District Manager on 02/15/19 at 10:25 AM, revealed he was currently filling in as the role of housekeeping supervisor at the facility due to the position was currently not filled. He stated he would expect a seven (7) step washroom cleaning to have been completed daily for Resident #17's bathroom. He stated he did not recall anyone reporting that Resident #17's commode was soiled and needed attention. He revealed he was not sure how Resident #17's commode had been missed for two (2) consecutive days but would investigate the matter.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan that was developed and/or implemented to meet the residents' preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one (1) of twenty-five (25) sampled residents (Resident #20). Resident #20 was prescribed [MEDICATION NAME] 75 milligrams (mg) (anti-platelet) and Aspirin 325 mg daily. However, there was no documented evidence a care plan was initiated to monitor resident for complications of the medications. In addition, the resident had an uncontrolled nosebleed and was sent to the emergency roiagnom on [DATE]; however, the care plan was not revised due to an uncontrolled nose bleed, not reflected on the comprehensive care plan. The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice, last revised (MONTH) (YEAR), revealed it is the practice of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Record review revealed the facility admitted Resident #20 on 07/13/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of the Physician's Order Sheet for February, 2019, revealed to administer [MEDICATION NAME] 75 mg one tablet orally every day; and, Aspirin 325 mg coated tablet one (1) tablet orally every day. Review of Nursing Progress Note, dated 01/25/19 at 11:22 AM revealed Resident #20 had a nose bleed and after multiple unsuccessful attempts to stop the bleeding, the physician was notified and the resident was sent to the emergency room for evaluation. Review of the Comprehensive Care Plan, dated 07/25/16, revealed Resident #20 has multiple medical [DIAGNOSES REDACTED]. Further review revealed the listed approaches included Antiplatelet/Aspirin medication as ordered. There is no documented evidence there was a care plan initated for provision of resident care related to antiplatelet / aspirin therapy. Further review of the Comprehensive Care Plans revealed no documented evidence the nose bleed was recorded on the care plans. Interview with Registered Nurse (RN) #1 on 02/15/19 at 12:36 PM revealed she was responsible for updating the care plans, and the resident should have had a care plan for taking a blood thinner but did not. RN #1 stated it was an over sight as was the nose bleed. Interview with the Director of Nursing (DON) on 02/15/19 at 02:10 PM, revealed the facility is monitoring for bleeding via the Medication Administration Record/Treatment Administration Record (MAR/TAR). However, there is no care plan related to the resident taking [MEDICATION NAME] and ASA. The DON stated she does not feel like there needs to be a care plan for [MEDICATION NAME] and ASA because they are monitoring signs and symptoms of bleeding on the MAR/TAR.

Based on interview, record review, and review of facility 24 hour Report, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the residents In making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of [REDACTED].#20). Resident #20 was seen by an ophthalmologist on 01/22/18 and recommendations were made for the resident to be evaluated by a cataract surgeon. An appointment was scheduled for 02/19/18, however, the resident was a no show, as the resident refused to go to the appointment. He/she was again scheduled to see the ophthalmologist on 08/27/18, but he/she was out of the facility for another doctor's appointment and was not seen by the ophthalmologist. There was no documented evidence the facility attempted to schedule another appointment with the surgeon or followed up with the resident related to future appointments with the cataract surgeon or his/her wishes for future appointments. In addition, it has been over one (1) year since the resident has had an eye exam. The findings include: Interview with the Director of Nursing (DON) on 02/15/19 at 2:10 PM revealed the facility does not have a policy related to vision exams. She stated the facility follows the federal guidelines to assure the residents are seen as needed. Additionally, the DON stated the residents are seen by specialists more frequently than every year if they choose to do so. Record review revealed the facility admitted Resident #20 on 07/13/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/12/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of the Physician's Note, dated 01/22/18, revealed Resident #20 was seen by the Ophthalmologist on 01/22/18 with chief complaint eyes not so good/worse. The plan was to monitor at regular intervals as the [MEDICAL CONDITION] were visually significant with recommendation for evaluation by a cataract surgeon and follow up in six (6) months 07/2018). Review of the Departmental Note dated 01/22/18 revealed Resident #20 had an appointment with a cataract surgeon on 02/19/18 at 1:00 PM; however, there was no documented evidence the resident was seen by the surgeon. Interview with the receptionist at the cataract surgeon's office on 02/15/19 at 11:20 AM revealed the referral was received from the facility and an appointment was scheduled for 02/19/18; however, the resident did not show up for the appointment. She stated the appointment was not canceled, the resident was a no show and another appointment has not been scheduled. Review of the facility's 24-Hour Report dated 02/19/18, revealed the resident refused to go to the appointment with the surgeon stating I'm not having surgery. Review of the note from the contract ophthalmologist dated 08/27/18, revealed Resident #20 had an appointment on this day, however, the appointment was canceled as the resident was out of the facility. However, further record review revealed no documented evidence that an appointment was rescheduled with the cataract surgeon, that the facility had interviewed the resident to determine his/her wishes regarding future appointments with a cataract surgeon, or had attempted to reschedule an appointment with the contracted eye doctor despite resident's complaints of on-going vision problems. Interview with Resident #20 on 02/12/19 at 1:13 PM revealed he/she is going blind. Resident #20 stated he/she is seeing black floaters and he/she has told the nurses about the vision problems but he/she had not been scheduled for an eye appointment. Interview with the DON on 02/14/19 at 3:14 PM and on 02/15/19 at 2:10 PM revealed Resident #20 saw the ophthalmologist on 01/22/18 and requested another appointment that was scheduled on 08/27/18. The DON stated the resident missed the 08/27/18 appointment because he/she was at an appointment with the cardiologist; and, she does no know why another appointment was not scheduled,. The DON further stated there is no documentation evidence that there was another attempt to get the resident another appointment for the surgeon after 02/19/18.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for one (1) of twenty-five sampled residents (Resident #32). Three (3) observations revealed improper positioning of Resident #32's urinary catheter tubing and drainage bag placement. The findings include: A signed statement from the Administrator and the Director of Nursing, dated 02/14/19, revealed the facility does not have a policy for urinary catheter care. However, review of the facility policy titled, Catheter Care, not dated, revealed to secure catheter properly. Coil and secure tubing to the bed. Review of the facility policy titled, Infection Control Tracking and Trending, last revised September, 2013, revealed the purpose of the policy was to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. Record review revealed the facility admitted Resident #32 on 01/26/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 12/26/18, revealed the facility did not complete the Brief Inventory of Mental Status (BIMS) exam, the resident had long-term and short-term memory impairment with severely impaired cognition, which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total care with activities of daily living (ADL) and has an indwelling urinary catheter. Observation on 02/13/19 at 10:44 AM revealed Resident #32's urinary catheter tubing was hanging from the bedside and looped to the drainage bag, not coiled and secured to the bed per facility policy. Observations on 02/13/19 at 3:36 PM and on 02/14/19 at 5:36 PM revealed the urinary catheter drainage bag covered with a dignity bag was laying flat on the floor at bedside, not hanging from the bed frame. Interview with Certified Nurse Assistant on 02/15/19 at 12:51 PM revealed when she was in the resident's room on 02/14/19, she did not notice the position of the catheter drainage bag, but it should not have been laying flat on the floor. Interview with Licensed Practical Nurse (LPN) #1 on 02/15/19 at 10:05 AM revealed the urinary catheter drainage bag should not be flat on the floor, it should be hanging from the bed frame to promote proper urine flow. Interview with Registered Nurse (RN) #1, Unit Manager, on 02/15/19 at 10:18 AM revealed the catheter drainage bag should be on the side of the bed away from the door in a privacy bag, and should be hanging from the bed frame. RN #1 stated if it is not hanging from the bed frame it could create too much tension. The RN further stated I did see the catheter bag on the floor yesterday, but there was no other choice because the bed was in a low position. RN #1 revealed she expected the catheter drainage bag not to rest flat on the floor, as it should be hung from the bed frame after it has been emptied, and I should have noticed it. Interview with the Director of Nursing (DON) on 02/15/19 at 02:10 PM revealed she expected staff to ensure the bedside drainage bag be in a privacy bag and hanging on bed frame. She stated she expected the staff to monitor the position of the bedside drainage bag with every round and on care partner rounds. The DON revealed if the privacy bag and the catheter drainage bag is observed flat on the floor, then it should be hung up on the bed frame to help the flow and prevent infection.

Based on interview, record review, review of emergency room Documentation of Transfer form and Discharge Summary, and review of the Centers For Medicare and Medicaid Services Federal Regulation F-Tag 157 it was determined the facility failed to ensure one (1) of three (3) sampled resident's (Resident #1) physician was notified when there was a potential need to alter treatment. Resident #1 had antibiotic therapy ordered due to the development of a rash and an increased temperature on 01/20/16. Resident #1 continued to have elevated temperatures, emesis, and poor fluid intake after the initial order to start antibiotic therapy. However, the facility failed to notify the physician of the potential need to alter treatment. Resident #1 was identified as unresponsive, lethargic, respirations shallow and skin turgor poor on 01/25/16 and was sent to the hospital. Resident #1 hospitalized for [REDACTED]. The findings include: Interview with the Director of Nursing (DON), on 03/04/16 at 11:05 AM, revealed the facility had no specific policy for physician notification and used the Centers For Medicare and Medicaid Services Federal Regulation F-Tag 157 for guidelines on notifying the physician. Review of the Medicare and Medicaid Services Federal Regulation F-Tag 157 revealed the facility must immediately consult with the resident's physician when there is a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Record review revealed the facility readmitted Resident #1 on 12/09/12 with diagnoses, which included Dementia, Anxiety, [MEDICAL CONDITION], Dysphagia, Muscle Weakness, Essential Hypertension, Abnormal Posture, and Cognitive Communication Deficit. Review of a Nurse's Note, dated 01/20/16 at 4:50 PM, revealed Resident #1 was noted to have a decline in alertness, a rash to the trunk and an elevated temperature. The physician was notified and an order was received for an antibiotic. Review of the Nurse's Notes, dated 01/21/16 at 3:31 AM, revealed Resident #1 had two (2) episodes of emesis. Further review revealed Resident #1 was assessed as having a temperature of 100.9 degrees Fahrenheit (F) (normal for resident: 97.3 degrees F), on 01/22/16 at 2:19 AM; 99.6 degrees F on 01/22/16 at 5:48 AM and on 01/22/16 at 3:57 PM; and, 99.4 degrees F on 01/24/16 at 2:25 PM. However, further review revealed there was no documented evidence the physician was made aware of the resident's continued increased temperature while on antibiotic therapy. Review of a Nurse's Note, dated 01/23/16 at 2:51 PM, revealed Resident #1 was fed by staff and only ate a few bites. Review of Resident #1's Consumption Records for 01/23/16, revealed Resident #1 did not consume any food or fluid intake at breakfast, lunch or dinner. Further review of the Nurse's Notes, revealed on 01/24/16 at 2:25 PM, Resident #1 had a temperature of 99.4 degrees F. Review of Resident #1's Consumption Record for 01/24/16, revealed the resident only consumed 120 Cubic Centimeters (cc), of fluid that day. However, there was no documented evidence the physician was notified of the resident's decreased intake. Review of the January 2016 Intake Records for Resident #1, revealed Resident #1's previous average daily fluid intake from 01/03/16 through 01/16/16 was 1,577 cc based on documented intakes. Review of a Nurse's Note, dated 01/25/16 at 2:00 PM, revealed Resident #1 was noted to be unresponsive, lethargic, respirations were shallow, and skin turgor was poor. The Advanced Practice Registered Nurse (APRN) was notified and an order was received to send Resident #1 to the emergency room (ER) for evaluation. Review of the emergency room (ER) Documentation of Transfer form, dated 01/25/16 at 3:00 PM, revealed Resident #1 was being transferred to the hospital from the ER due to [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary, dated 02/03/16, revealed Resident #1 was treated for [REDACTED]. Further review of the Discharge Summary, revealed the physician believed the Acute Kidney Injury was likely due to dehydration. Interview (Post Survey) with Registered Nurse (RN)/MDS Coordinator, on 03/14/16 at 2:09 PM, revealed she cared for Resident #1 on 01/22/16. She stated she would expect a physician to be notified if a resident continues with elevated temperatures over the course of several days, especially a resident that is receiving antibiotic therapy. She stated, she was unaware that Resident #1 had ongoing elevated temperatures when she cared for Resident #1 on 01/22/16 and in hindsight she should have looked back at the previous week of nurses notes which would have shown Resident #1 had an ongoing temperature over the course of several days. Interview (Post Survey) with Licensed Practical Nurse (LPN) #2, on 03/14/16 at 2:27 PM, revealed she cared for Resident #1 on 01/24/16 and did not recall Resident #1's condition being acute or in need of a physician's notification at that time. She stated she was unaware that Resident #1 had an ongoing temperature over the course of several days when she took care of him/her on 01/24/16 and that if she would have been aware she would have notified the physician. Interview with LPN #1 who has cared for Resident #1, on 03/02/16 at 10:42 AM, revealed she would have expected licensed staff to notify the physician anytime a resident's acute clinical condition was not improving and anytime a resident had an ongoing elevated temperature. Interview with LPN #3 who worked on another unit, on 03/04/16 at 9:47 AM, revealed she expected all licensed staff to ensure a physician was notified if a resident continued to show elevated temperatures after starting antibiotic therapy. She also stated a physician should be notified if a resident had continually had low fluid intake accompanied by an elevated temperature. Interview with the LPN/House Supervisor, on 03/02/16 at 08:35 AM, revealed she expected licensed staff to be sure to notify the physician when a resident had a continued elevated temperature after being on antibiotic therapy. Interview with Assistant Director of Nursing (ADON), on 03/03/16 at 10:30 AM, revealed she expected all licensed staff to ensure the physician was made aware of any resident who continued to have elevated temperatures accompanied with low fluid intake as this could potentially cause dehydration. Interview with the Director of Nursing (DON), on 03/03/16 at 10:35 AM, revealed she would have expected licensed staff to inform the physician when a resident had continued elevated temperatures, and any other acute condition that was not improving or resolving. Interview with Resident #1's APRN, on 03/03/16 at 4:35 PM, revealed she would expect the facility to notify herself or the physician for any resident who had continued to have increased temperatures after starting an antibiotic and also for any resident that had continued to have low fluids consumption accompanied by ongoing elevated temperatures. Interview with the Administrator, on 03/04/16 at 10:23 AM, revealed she expected licensed staff to notify the physician if an acute illness or sickness that the resident was being treated and monitored for was not improving. She stated an ongoing temperature accompanied with low fluid intake would have warranted physician notification for guidance from the physician for possible altered treatment.

Based on interview, record review, review of the facility's policy, review of emergency room Documentation of Transfer form, and review of the hospital History and Physical and Discharge Summary, it was determined the facility failed to revise the plan of care for one (1) of three (3) sampled residents (Resident #1) when the resident's status changed. Resident #1 was identified as having a cough, rash, elevated temperature on 01/20/16, and was started on antibiotic therapy. In addition, the resident had an episode of emesis, an ongoing temperature over the next five (5) days. However, the facility failed to revise the resident's plan of care to address the antibiotic use and the increased risk of dehydration. Resident #1 was hosptalized on [DATE] for nine (9) days with [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy and procedure titled Care Plans - Comprehensive, revised October 2010, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Further review of this policy, revealed each resident's comprehensive Care Plan should incorporate identified problem areas and risk factors associated with identified problems. The care plan should build on the resident's strengths reflect the resident's expressed wishes regarding care and treatment goals. In addition, the care plan should have timetables and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitated program, and reflect currently recognized standards of practice for problem areas and conditions. The policy further revealed assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Record review revealed the facility readmitted Resident #1 on 12/09/12 with diagnoses, which included Dementia, Anxiety, Dysphagia, Muscle Weakness, Abnormal Posture, and Cognitive Communication Deficit. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/29/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of a Nurse's Note, dated 01/20/16 at 4:50 PM, revealed Resident #1 was noted to have a decline in alertness, a rash to the trunk and an elevated temperature on 01/20/16; the resident was placed on an antibiotic. Further review of the Nurse's Notes, revealed Resident #1 had a temperature of 100.9 degrees Fahrenheit (F) on 01/22/16 at 2:19 AM; 99.6 degrees F on 01/22/16 at 5:48 AM and at 3:57 PM; and 99.4 degrees F on 01/24/16 at 2:25 PM. In addition, review of Resident #1's Consumption Records revealed Resident #1 did not consume any food or fluid intake at breakfast, lunch or dinner on 01/23/16 and only 120 Cubic Centimeters (cc) of fluid on 01/24/16. However, review of Resident #1's current Interdisciplinary Care Plans, dated 08/27/15, 08/29/15, 10/07/15, and 10/09/15, revealed there were no revisions to the care plan to address Resident #1's use of an antibiotic, his/her ongoing temperature and decreased intake, which placed the resident at an increased risk of dehydration. Review of a Nurse's Note, dated 01/25/16 at 2:00 PM, revealed Resident #1 was sent to the emergency room (ER) and was hospitalized for [REDACTED]. Review of the Discharge Summary revealed the resident was discharged back to the facility on [DATE]. However, further review of Resident #1's current interdisciplinary care plans dated 08/27/15, 08/29/15, 10/07/15, 10/09/15, revealed there were no revisions made to the care plans to address the resident's identified risk for dehydration. Interview with the Assistant Director of Nursing (ADON), on 03/03/16 at 10:30 AM, revealed she would have expected Resident #1's care plans to have been updated to reflect his/her changes in his/her clinical condition. Interview (Post Survey) with Registered Nurse (RN)/MDS Coordinator, on 03/14/16 at 2:09 PM, revealed the nursing leadership updates care plans with resident condition changes, treatment changes and anything pertinent to the resident's overall care. She stated nursing management brings the previous twenty-four (24) hours worth of nursing notes and physician's orders [REDACTED]. She further stated, there was a great deal of orders and nurses notes to look through daily that some stuff could possibly get missed and not care planned. Interview (Post Survey) with the facility Wound Care Nurse, on 03/14/16 at 3:05 PM, revealed the floor nurses are not responsible for updating the care plans. She stated the nursing management team updates the care plans during the morning department head meeting. She revealed the nursing management team brings all of the nursing notes and physicians orders for all residents that have been created in the previous twenty-four (24) hours to be reviewed, followed up on and care planned, if indicated. She further stated if something was not care planned it may have been missed in the process or it may have been something that the team did not think was pertinent. Interview with the Director of Nursing (DON), on 03/03/16 at 10:35 AM, revealed she expected care plans to be updated on an ongoing basis with any clinical condition changes or with any new high-risk conditions that arise for residents. She further stated Resident #1's care plans should have been updated with his/her condition changes and identified problems that arose from his/her acute medical conditions that led to a hospitalization . The DON stated all nurses were able to and responsible for updating care plans with new orders, treatments, and changes that were pertinent to the resident. She further stated all Physicians' Orders written during the course of the day were taken to the Department Head morning meeting the following day and the team was to assure anything that was pertinent had been care planned and/or followed up on. Interview with the Administrator, on 03/04/16 at 10:23 AM, revealed she expected the facility to follow the care plan policy and procedure.

Based on interview, record review, facility policy review, review of emergency room Laboratory Report and hospital Discharge Summary, it was determined the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was identified as having a cough, rash, elevated temperature on 01/20/16, and was started on antibiotic therapy. The resident had an episode of emesis and an ongoing temperature over the next five (5) days; however, the facility failed to conduct ongoing assessments to identify if the resident was showing signs and symptoms of dehydration; if the resident was receiving adequate fluids; if the resident's temperature was controlled with the use of Tylenol; and, if the antibiotic was effective. On 01/25/16, Resident #1 was identified to be unresponsive, was lethargic, respirations were shallow, and skin turgor was poor. Resident #1 was hosptalized on [DATE] for nine (9) days with [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, last revised October 2010, revealed the nursing staff will help the physician identify any complications and or problems that occurred during a recent hospital stay, which may indicate the risk of additional acute problems. Further review of the policy and procedure, revealed the nursing staff will monitor and document the resident's progress and responses to treatment. Interview with the Director of Nursing (DON), on 03/03/16 at 10:35 AM, revealed the facility had no policy and procedure for assessing and monitoring residents related to antibiotic therapy or dehydration and was unable to provide any policy and procedure related to these areas. Record review revealed the facility readmitted Resident #1 on 12/09/12 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/29/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of the Nutritional at Risk Plan of Care, dated 10/09/15, revealed interventions for staff to monitor for signs and symptoms of dehydration to include dry tenting skin, dry mucous membranes and decreased urinary output. However, the care plan did not address the amount of assessed fluid needs and the resident's normal intakes. Review of the physician's orders [REDACTED]. Review of a Nurse's Note, dated 01/17/16 at 1:43 PM, revealed Resident #1's family came in to visit and reported Resident #1 had vomited on himself/herself. Further review of the Nurse's Notes revealed there was no documented evidence of ongoing assessments due to the resident's change in condition until 01/20/16 at 4:50 PM (three {3}days later), when it was noted Resident #1 had a cough, a rash to his/her trunk of body, was not as alert, and had an elevated temperature of 100.6 degrees Fahrenheit (F) (resident normal: 97.3 degrees F). The physician was notified and the resident was placed on an antibiotic. Further review of the Nurse's Notes revealed there was no documentation of another assessment of Resident #1 until 01/21/16 at 3:31 AM. The Nurse's Note stated Resident #1 had two (2) vomiting episodes at the beginning of the shift and the resident was medicated with an as needed (PRN) nausea medication with no further episodes noted. Review of a Nurse's Note, dated 01/22/16 at 2:19 AM, revealed Resident #1 had an elevated temperature of 100.9 degrees F and PRN Tylenol was given. Further review of the Nurse's Notes, revealed on 01/22/16 at 3:57 PM, Resident #1 had a temperature of 99.6 degrees F and received PRN Tylenol at approximately 2:00 PM. However, review of the Nursing Notes, dated 01/20/16 through 01/22/16, and review of the January 2016 Medication Administration Record (MAR) revealed there was no documented evidence Resident #1 was assessed after the administration of the Tylenol to determine if the medication was effective. Review of Resident #1's Consumption Records, revealed there was no documentation that Resident #1 had consumed any food or fluid intake at breakfast, lunch or dinner on 01/23/16 and only consumed 120 cc of fluid on 01/24/16. However, further review of the Nursing Notes, dated 01/23/16 and 01/24/16, revealed there was no documented evidence the resident was assessed for signs and symptoms of dehydration to include dry tenting skin, dry mucous membranes and decreased urinary output. Review of a Nurse's Note, dated 01/25/16 at 2:00 PM, revealed at 12:30 PM Resident #1 was noted to be unresponsive, lethargic, respirations were shallow, and skin turgor was poor. The Advanced Practice Registered Nurse (APRN) was notified and Resident #1 was sent to the emergency room (ER) to be evaluated. Review of the emergency room (ER) laboratory results, dated 01/25/16 at 1:22 PM, revealed Resident #1 had elevated levels of Hemoglobin 16.8 (normal range 12.2 - 16.20), Hematocrit 53.0 (normal range 37.0 - 47.0) , Blood Urea Nitrogen (BUN) 111 (normal range 7 - 18), Chloride 126 (normal range 98 -107) and Sodium 159 (normal range (136 - 145) which indicated the resident was dehydrated. Review of Resident #1's Discharge Summary, dated 02/03/16, revealed Resident #1 was treated for [REDACTED]. Further review of the Discharge Summary, revealed the physician documented the Acute Kidney Injury was likely due to dehydration, Resident #1 was given Intravenous (IV) fluids, Resident #1's mentation improved with improving Kidney Injury and his/her Urinary Tract Infection [MEDICAL CONDITION] and he/she was back to baseline by day of discharge. Interview with emergency room Registered Nurse (RN) #1 on 03/02/16 at 3:30 PM, revealed Resident #1 was received in the ER with extremely dry and crusted lips, tongue and oral mucosa which was an indicator Resident #1 was dehydrated. He further stated Resident #1 had blood-work at the hospital and his/her laboratory values were also an indicator Resident #1 was dehydrated. RN #1 also stated, Resident #1 had to receive intravenous (IV) fluid replacement because he/she was dehydrated. Interview with the ER Physician, on 03/03/16 at 9:25 AM, revealed he was the attending physician in theER on [DATE] and he was very concerned about Resident #1 due to his/her level of dehydration. He stated Resident #1 had blood-work done which reflected elevated laboratory levels of hemoglobin, hematocrit, blood urea nitrogen (BUN), chloride and sodium that were indicative of true dehydration/fluid volume deficit and not due to a medical condition such as a renal impairment or disease process. He further stated he was very concerned with how dry and crusted Resident #1's lips and mouth were. The ER Physician stated Resident #1 had a dried mucus like crust covering his/her gums in his/her oral cavity which was also indicative of true dehydration and lack of fluid intake over a period of several days. He stated Resident #1's level of dehydration would have come from several days of minimal fluid intake and this was negligent due to this particular resident's cognitive and physical impairments, as he/she was dependent upon others to provide fluids as he/she would be unable to do so by himself/herself without assistance. Interview (Post Survey) with the MDS Coordinator, on 03/14/16 at 2:09 PM, revealed she cared for Resident #1 on 01/22/16. She stated she was on call that day and worked the unit Resident #1 resides on. She revealed she would have been expected to document on the MAR if she administered any type of PRN medication and she would have been expected to chart the follow up results of the PRN medication on the PRN flow sheet and in the nurses notes. Review of Nurse's Note, dated 01/22/16 at 3:57 PM, and January 2015 MAR, revealed the MDS Coordinator documented Resident #1 had a temperature of 99.6 degrees F and was given Tylenol at approximately 2:00 PM. However, further review of Resident #1's Nursing Notes, dated 01/22/16 and January 2016 MAR revealed there was no documented evidence an assessment was completed to determine if the Tylenol was effective. Continued interview with MDS Coordinator, revealed she must have forgot to do the follow up charting on the PRN Tylenol, but should have done so. She also stated she had done an assessment on Resident #1 for dehydration signs and symptoms due to the elevated temperature but had forgot to add that to her nurse's note entry. She further stated she would have notified the physician if the assessment showed any signs and symptoms of dehydration. Interview with Licensed Practical Nurse (LPN) #2, on 03/01/16 at 11:25 AM, revealed she would have expected licensed staff to document on the MAR any medications given and to follow up on the medication given to see if it was effective. Further interview (Post Survey) with LPN #2, on 03/14/16 at 2:27 PM, revealed she cared for Resident #1 on 01/24/16. LPN #2 stated she remembered assessing Resident #1 for signs and symptoms of dehydration but must have forgot to chart it in the nurse's notes, but she always assesses a resident for signs and symptoms of dehydration if they have an elevated temperature. She also stated she would have notified Resident #1's doctor if she found Resident #1 to have had any signs and symptoms of dehydration. Interview with LPN #1, on 03/02/16 at 10:42 AM, revealed she would have expected licensed staff to document on the MAR any medications given and to follow up on the medication to see if it was effective. She further stated licensed staff was expected to assess and document every shift when a resident is on an antibiotic. LPN #1 stated the assessment should include assessing for adverse side effects of the antibiotic and for the reason the antibiotic therapy was initiated to determine if it was effective. Interview with LPN #3, on 03/04/16 at 9:47 AM, revealed she expected all licensed staff to document on the MAR anytime medications were given and to follow up on the PRN medication given to see if effective. She stated licensed staff should assess and document every shift when a resident was on an antibiotic. LPN #3 stated the assessment should include assessing for adverse side effects of the antibiotic and the resident's acute illness or acute change in condition. Interview with the LPN/House Supervisor, on 03/02/16 at 08:35 AM, revealed she expected licensed staff to always document any PRN medication given on the MAR and to follow up on any PRN medication for the results of the medication given. She further stated she expected licensed staff to assess for signs and symptoms of dehydration for any resident that had an elevated temperatures and poor fluid intake. Interview with Assistant Director of Nursing (ADON), on 03/03/16 at 10:30 AM, revealed she expected all licensed staff to document on the MAR anytime medications were given and to follow up on the PRN medications given. She also stated following up on PRN medication would be important to see if the medication was effective in treating the resident's condition. The ADON stated she expected licensed staff to assess the resident and document every shift when a resident was on an antibiotic and had an acute illness. Interview with the DON, on 03/03/16 at 10:35 AM, revealed she expected licensed staff to ensure documentation on the MAR if the medication was given and to also follow up on the medication to see if it was effective. She stated she expected licensed staff to do ongoing assessments when a resident has any kind of acute illness or recent decline in baseline conditions. The DON also stated she would have expected licensed staff to assess for and document any signs and symptoms of dehydration with any resident who had poor fluid intake and an ongoing elevated temperature. Interview with Resident #1's APRN on 03/03/16 at 4:35 PM, revealed she would have expected the nursing staff to have followed up on any medication that was given for elevated temperatures to see if the medication was effective and if the elevated temperature was relieved or resolved. She stated a prolonged temperature increase would contribute to the risk of dehydration and warrant an increase in fluid consumption. She further stated that was why it was very important to follow up on elevated temperatures. Interview with the Administrator on 03/04/16 at 10:23 AM, revealed she expected licensed staff to assess residents thoroughly and ongoing during any type of acute illness or sickness in which they were being treated or monitored. She further stated she would expect all licensed nurses to document any PRN medication given on the MAR and to follow up on the PRN medication for results as to whether the medication was effective or not effective.

Based on interview, record review, review of facility policy, review of emergency room Laboratory Report and Documentation of Transfer Form, and Hospital Discharge Summary, it was determined the facility failed to have an effective system in place to ensure one (1) of three (3) sampled residents (Resident #1) was provided with sufficient fluid intake to maintain proper hydration and health. Resident #1 began having episodes of vomiting on 01/17/16 and an elevated temperature on 01/20/16. The resident was placed on antibiotics on 01/20/16; however, the resident continued to have a temperature and had another episode of vomiting on 01/21/16. The facility failed to ensure the amount of fluid the resident consumed was documented consistently on his/her consumption records to be able to determine if the resident's intake was decreasing; and, they failed to have an effective system in place to ensure the resident's fluid intake was monitored. In addition, the facility failed to provide ongoing assessments to determine if the resident had signs and symptoms of dehydration; and, failed to notify the physician of the resident's ongoing temperature and decreased fluids while on the antibiotic. On 01/25/16, Resident #1 was assessed to be unresponsive, lethargic, respirations shallow, and having poor skin turgor. Resident #1 was sent to the emergency room and was hosptalized on [DATE] for nine (9) days with [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy titled, 'Hydration-Clinical Protocol' last revised October 2010, revealed the physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte; for example, those with prolonged vomiting, diarrhea, or fever or who are not eating or drinking well. Record review revealed the facility readmitted Resident #1 on 12/09/12 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/29/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. In addition, the facility assessed the resident as requiring extensive assistance of one (1) staff for eating. Review of Resident #1's Nutritional Data Set and Progress Note (assessment), completed by the Registered Dietician (RD), dated 10/09/15, revealed the facility assessed Resident #1's daily fluid needs to be 1600 Cubic Centimeters (cc) -1920 cc daily. However, further review revealed the section to be completed for past fluid intake to determine if the resident was at risk for dehydration was blank. There was no documented evidence the Dietician assessed the resident's past fluid intake to determine if the resident was at risk for dehydration. Interview (Post Survey) with RD, on 03/11/16 at 8:24 AM, revealed she was not the Dietician when the Nutritional Data Set and Progress Note was completed on 10/09/15. However, she stated the Nutritional Data Set and Progress Note was an assessment completed by the RD when a resident was admitted to the facility, with any significant change in weight gain or weight loss, annually and any time a resident was admitted to the hospital and gone over twenty-four (24 hrs). The RD stated it was very important for the Nutritional Data Set to be completed in its entirety in order to get an accurate overall picture of the resident being assessed. She further stated the portion of the assessment related to the resident's current fluid intake, should be completed as this would give important information in regards to the facility's need to attempt other possible interventions to improve a resident's fluid intake if that particular resident had not been consuming an adequate amount. Review of the Nutritional at Risk Plan of Care, dated 10/09/15, revealed an intervention for staff to monitor for signs and symptoms of dehydration to include dry tenting skin, dry mucous membranes and decreased urinary output. However, the care plan did not address the amount of assessed fluid needs and the resident's normal intakes. Review of Resident #1's December 2015 and January 2016 Consumption Logs revealed there were to many undocumented spaces (blanks) to determine how much fluid the resident consumed daily on a consistent basis to determine if the resident was meeting his/her fluid needs. Further review revealed the amount of fluid the resident consumed was only documented for five (5) out of eighteen (18) meals from 01/17/16 through 01/22/16. Review of a Nurse's Note, dated 01/17/16 at 1:43 PM, revealed Resident #1's family came in to visit and reported Resident #1 had vomited on himself/herself. Further review of the Nurse's Notes revealed there was no documented evidence the resident's condition was assessed again until 01/20/16 at 4:50 PM (three {3}days later), when it was noted Resident #1 had a cough, a rash to trunk of body, was not as alert, and had an elevated temperature of 100.6 degrees Fahrenheit (F) (normal for resident 97.3 degrees F). The resident was administered Tylenol for the increased temperature. Review of Resident #1's physician's orders [REDACTED]. Further review of the Nurse's Notes revealed there was no further documentation of Resident #1's condition until 01/21/16 at 3:31 AM. The Nurse's Note revealed Resident #1 had two (2) vomiting episodes at the beginning of the shift and the resident was medicated with an as needed (PRN) nausea medication with no further emesis noted. On 01/22/16 at 2:19 AM, Resident #1 had an elevated temperature of 100.9 degrees F and PRN Tylenol was given. A Nurse's Note, dated 01/22/16 at 5:48 AM, revealed Resident #1 had a temperature of 99.7 degrees F. Further review of the Nurse's Notes, revealed on 01/22/16 at 3:57 PM, Resident #1 had a Temperature of 99.6 degrees F and received PRN Tylenol at approximately 2:00 PM. Record review revealed there was no evidence the resident was assessed for signs and symptoms of dehydration related to the resident's emesis and ongoing temperature. Review of a Nurse's Note, dated 01/23/16 at 2:51 PM, revealed Resident #1 was fed by staff and only ate a few bites but drank well; and, the resident's daughter was made aware of the resident not eating well this shift. Review of Resident #1's Consumption Records for 01/23/16, revealed there was no documented evidence of food or fluid intake at breakfast, lunch or dinner. Further review revealed Resident #1 had a temperature of 99.4 degrees F on 01/24/16 at 2:25 PM and review of the Consumption Record revealed the facility documented the resident consumed 120 cc of fluid that day. However, review of the Nursing Notes for 01/23/16 and 01/24/16 revealed there was no documented evidence the facility assessed Resident #1 for any signs and symptoms of dehydration to include dry tenting skin, dry mucous membranes and decreased urinary output related to the resident's decreased fluid intake and continued temperature. Review of a Nurse's Note, dated 01/25/16 at 2:00 PM, revealed Resident #1 was noted to be unresponsive, lethargic, respirations shallow and had skin turgor poor. The Advanced Practice Registered Nurse (APRN) was notified of Resident #1's condition and an order was received to send Resident #1 to the emergency room (ER) for evaluation. Review of physician's orders [REDACTED].#1 was to be sent to the emergency room for evaluation due to being unresponsive with shallow respirations. Interview with Licensed Practical Nurse (LPN) #1, on 03/02/16 at 10:42 AM, revealed she sent Resident #1 to theER on [DATE] for an evaluation. LPN #1 stated she could tell Resident #1 was not acting like his/her normal self and was very sluggish with shallow respirations. She stated she called the physician's office and spoke with the Advanced Practice Registered Nurse (APRN) and explained Resident #1's deteriorating condition and the APRN ordered to send Resident #1 to the ER for an evaluation. LPN #1 stated she called and followed up on Resident #1 later after he/she had been sent to the ER. She stated the ER staff informed her Resident #1 was being admitted to the hospital with [REDACTED]. LPN #1 further stated she would have expected staff to attempt to encourage and increase fluids for a resident who had an elevated temperature and had poor fluid consumption. The LPN stated she was not aware of the facility's policy to monitor fluid and hydration status. Review of the emergency room (ER) laboratory results, dated 01/25/16 at 1:22 PM, revealed Resident #1 had elevated levels of Hemoglobin 16.8 (normal range 12.2 - 16.20), Hematocrit 53.0 (normal range 37.0 - 47.0) , Blood Urea Nitrogen (BUN) 111 (normal range 7 - 18), Chloride 126 (normal range 98 -107) and Sodium 159 (normal range (136 - 145) which indicated the resident was dehydrated. Review of the ER documentation of transfer, dated 01/25/16 at 3:00 PM, revealed Resident #1 was being transferred to the hospital from the ER due to [DIAGNOSES REDACTED]. Review of Hospitalist Progress Notes, dated 01/26/16 through 02/02/16, revealed Resident #1 was receiving intravenous fluids (IV) to treat dehydration. Review of Resident #1's Discharge Summary, dated 02/03/16, revealed Resident #1 was treated for [REDACTED]. Further review of the Discharge Summary, revealed the physician documented he believed the Acute Kidney Injury was likely due to dehydration. Interview with emergency room Registered Nurse (RN) #1, on 03/02/16 at 3:30 PM, revealed he was the ER Nurse when Resident #1 arrived at theER on [DATE]. He stated Resident #1 was received in the ER with extremely dry and crusted lips, tongue and oral mucosa which was an indicator Resident #1 was dehydrated. He further stated Resident #1 had blood-work done and his/her laboratory values were also an indicator Resident #1 had dehydration. The emergency room RN stated, Resident #1 received intravenous (IV) fluid replacement because he/she was dehydrated. Interview with ER Physician, on 03/03/16 at 9:25 AM, revealed he was the attending physician in theER on [DATE] when Resident #1 was sent to the ER for an evaluation. He stated he was very concerned about Resident #1 due to the resident's level of dehydration. He stated Resident #1 had blood-work done and had elevated laboratory levels of hemoglobin, hematocrit, blood urea nitrogen (BUN), chloride and sodium that were indicative of true dehydration/fluid volume deficit and not due to a medical condition such as a renal impairment or disease process. He further stated he was very concerned with how dry and crusted Resident #1's lips and mouth. He stated Resident #1 had a dried mucus like crust covering his/her gums in his/her oral cavity which was also indicative of true dehydration and lack of fluid intake over a period of several days. He stated Resident #1's level of dehydration would have had to result from several days of minimal fluid intake and he felt the facility was negligent because the resident was dependent on others to provide fluids as he/she was not able to provide his/herself fluids due to his/her cognitive and physical impairments. Interview with Resident #1's Power of Attorney (POA)/Daughter on 03/01/16 at 6:30 PM, revealed she felt like the facility was not adequately feeding or providing fluids for Resident #1. She stated she often came to the facility and staff would report Resident #1 did not eat or drink much or had refused food and fluids. The Daughter stated Resident #1 needed ample time to consume fluids and food and he/she was slow at consuming food and fluids and due to this, staff did not take the time to ensure Resident #1 had ample consumption of food and fluids. She also stated Resident #1 had to have extra encouragement and cueing to consume adequately. Interview with Certified Nursing Assistant (CNA) #1 on 03/01/16 at 11:17 AM, revealed CNA #1 stated Resident #1 was on thickened liquids and did not drink well at times. CNA #1 stated she could recall Resident #1 being sent out to the hospital on [DATE] due to being sick, non-responsive, and not eating or drinking much. CNA #1 stated she remembered hearing that Resident #1 was admitted to the hospital with [REDACTED].#1 had to be fed all meals by a nurse now to be sure he/she received adequate fluids and nutrition. Interview with CNA #2, on 03/01/16 at 11:22 AM, revealed Resident #1 did not drink fluids well and staff have to keep encouraging him/her to take drinks throughout the day. CNA #2 stated she remembered hearing that Resident #1 was admitted to the hospital because he/she had been dehydrated. She stated Resident #1 was to be fed all meals by licensed staff now since returning from the hospital. CNA #2 stated this was to ensure Resident #1 was getting adequate fluids and food. Interview with LPN #2, on 03/01/16 at 11:25 AM, revealed she remembered Resident #1 was sent to theER on [DATE] because he/she had become kind of unresponsive with shallow respirations and was not acting normal in regards to responding to physical and verbal stimuli. LPN #2 stated due to Resident #1's overall deterioration he/she was sent to the ER for evaluation and was admitted with Dehydration and a Urinary Tract Infection. LPN #2 further stated Resident #1 was now to be fed by licensed staff for all meals because the resident did not eat or drink well and that's part of what led him/her to being admitted to the hospital with [REDACTED].#2 further stated she would have expected staff to attempt to encourage and increase fluids for a resident who had an elevated temperature and poor fluids consumption. She stated she was not familiar with how the facility ensures a resident consumes their assessed daily fluid needs on a daily basis. Interview with facility's Registered Dietician (RD) on 03/02/16 at 4:15 PM, revealed a resident's assessed daily fluid needs were very important and the assessed fluid needs were determined by taking into consideration the resident's overall medical condition and disease processes. She further stated, it would be important to attempt to meet the resident's assessed need. Interview with Resident #1's APRN, on 03/03/16 at 4:35 PM, revealed she would have expected the nursing staff to have notified herself or the physician due to Resident #1 having an ongoing elevated temperature after the antibiotic therapy was started and due to ongoing poor fluid intake by Resident #1. She further stated it was important to attempt to increase fluids in anyone who has an elevated temperature because this increased the need for more fluids. Interview with the Director of Nursing (DON), on 03/03/16 at 10:35 AM, revealed she would have expected her licensed nurses to have notified the physician or APRN due to Resident #1 having continued elevated temperatures and poor fluid intake over the course of several days. She stated she would also have expected staff to have attempted to encourage Resident #1 to increase his/her consumption of fluids due to the continued elevated temperature and poor fluid intake. The DON stated she was unsure what systems the facility had in place to ensure the resident's actual assessed fluids needs were being met. She also stated, the charge nurses on the floor were to be looking at consumption records at the end of their shifts and looking for any alert in regards to a resident refusing meals or having decreased fluid intake from the resident's usual consumption and if this is noted she would expect the nurse to take action at that time. The DON stated she was unsure what system was in place to ensure the charge nurses were checking resident consumption of fluid and nutrition at the end of their shifts.